Basic Information
| Provider Information | |||||||||
| NPI: | 1174526594 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THUNDER BAY EMERGENCY PHYSICIANS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2347 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495012347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
| FaxNumber: | 6165327230 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 W CHISHOLM ST | ||||||||
| Address2: | |||||||||
| City: | ALPENA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497071401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
| FaxNumber: | 6165327230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 01/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLAYTON | ||||||||
| AuthorizedOfficialFirstName: | BEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD OF THE GROUP | ||||||||
| AuthorizedOfficialTelephone: | 8009686866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5010009914 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | CI7552 | 01 | MI | RAILROAD MEDICARE GROUP | OTHER |