Basic Information
| Provider Information | |||||||||
| NPI: | 1013095173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE HURON OB GYN PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 S VAN DYKE RD | ||||||||
| Address2: | |||||||||
| City: | BAD AXE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484139614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892693923 | ||||||||
| FaxNumber: | 9892693983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 S VAN DYKE RD | ||||||||
| Address2: | |||||||||
| City: | BAD AXE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484139614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892693923 | ||||||||
| FaxNumber: | 9892693983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | MACCHIARELLA | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | BISCHER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9892693923 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | NK013377 | MI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1653210895 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 1603210171 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 4624157 | 05 | MI | MEDICAID | 4645433 | 05 | MI | MEDICAID |