Provider Demographics
NPI:1952420358
Name:UPPER PENINSULS SPORTS MEDICINE & THERAPY CENTER
Entity Type:Organization
Organization Name:UPPER PENINSULS SPORTS MEDICINE & THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NEVENHOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-228-2595
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-228-2595
Mailing Address - Fax:906-228-3313
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-228-2595
Practice Address - Fax:906-228-3313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001972261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30455OtherBLUE CROSS BLUE SHIELD
MI236591Medicare ID - Type UnspecifiedASSIGNED MEDICARE NUMBER