Basic Information
| Provider Information | |||||||||
| NPI: | 1467420901 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE OF NORTHERN MICHIGAN PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872460 | ||||||||
| FaxNumber: | 2314876596 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872460 | ||||||||
| FaxNumber: | 2314876596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 08/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2314872460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 99111316 | 01 | HIRSP | OTHER | CF8034 | 01 | RR MEDICARE | OTHER | 619706 | 01 | ANTHEM BCBS | OTHER | 110B410170 | 01 | MICHIGAN BCBS | OTHER | 20146 | 01 | PRIORITY HEALTH GROUP ID | OTHER |