Provider Demographics
NPI:1811183163
Name:CARLSON MEDICAL PC
Entity type:Organization
Organization Name:CARLSON MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CARLSON MEDICAL PC
Authorized Official - Prefix:
Authorized Official - First Name:VERNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-753-4665
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:S926 US HWY 41
Mailing Address - City:STEPHENSON
Mailing Address - State:MI
Mailing Address - Zip Code:49887-0400
Mailing Address - Country:US
Mailing Address - Phone:906-753-4665
Mailing Address - Fax:906-753-4366
Practice Address - Street 1:S926 US 41
Practice Address - Street 2:
Practice Address - City:STEPHENSON
Practice Address - State:MI
Practice Address - Zip Code:49887
Practice Address - Country:US
Practice Address - Phone:906-753-4665
Practice Address - Fax:906-753-4366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI048831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4654290Medicaid
MI4654290Medicaid