Basic Information
| Provider Information | |||||||||
| NPI: | 1396711636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GAYLORD FAMILY PRACTICE ASSOCIATES PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2219 | ||||||||
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| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497342219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897315092 | ||||||||
| FaxNumber: | 9897317639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 E M 32 | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497358378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897315092 | ||||||||
| FaxNumber: | 9897317639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 04/29/2010 | ||||||||
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| AuthorizedOfficialLastName: | LINGAUR | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9897315092 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080F910050 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |