Basic Information
| Provider Information | |||||||||
| NPI: | 1356585327 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NES OF PORT HURON, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742488 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003778721 | ||||||||
| FaxNumber: | 3046971155 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 ELECTRIC AVE | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480606587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109851580 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4154354591 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | DP7173 | 01 | RR MEDICARE | OTHER | 700G400410 | 01 | MI | BCBS | OTHER | 500G400400 | 01 | MI | BCBS - NP GROUP | OTHER | 1356585327 | 05 | MI | MEDICAID |