Basic Information
| Provider Information | |||||||||
| NPI: | 1356316186 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTORS SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DOCTORS SERVICES PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 802 S MAIN ST | ||||||||
| Address2: | STE 3 | ||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497212269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316273002 | ||||||||
| FaxNumber: | 2316276204 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 S MAIN ST | ||||||||
| Address2: | STE 3 | ||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497212269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316273002 | ||||||||
| FaxNumber: | 2316276204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALTZER | ||||||||
| AuthorizedOfficialFirstName: | RODERICK | ||||||||
| AuthorizedOfficialMiddleName: | JAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2316273002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DOCTORS SERVICES INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101006586 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1424279 | 05 | MI | MEDICAID |