Basic Information
Provider Information | |||||||||
NPI: | 1093921074 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIAN HEALTHCARE NETWORK, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3050 COMMERCE DR | ||||||||
Address2: |   | ||||||||
City: | FORT GRATIOT | ||||||||
State: | MI | ||||||||
PostalCode: | 480593819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8103854441 | ||||||||
FaxNumber: | 8103851540 | ||||||||
Practice Location | |||||||||
Address1: | 3350 GRATIOT BLVD | ||||||||
Address2: |   | ||||||||
City: | MARYSVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 480402121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8103644000 | ||||||||
FaxNumber: | 8103645995 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2007 | ||||||||
LastUpdateDate: | 09/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CUSUMANO | ||||||||
AuthorizedOfficialFirstName: | MIMMA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 8103858081 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   | MI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.