Basic Information
| Provider Information | |||||||||
| NPI: | 1245445972 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIAN HEALTHCARE NETWORK, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103854441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2425 MILITARY ST BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480606692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109845700 | ||||||||
| FaxNumber: | 8109841886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | CUSUMANO | ||||||||
| AuthorizedOfficialFirstName: | MIMMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8103858081 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.