Basic Information
Provider Information | |||||||||
NPI: | 1629018635 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCHAFER | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 406 KENT ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | MI | ||||||||
PostalCode: | 488751707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5176474166 | ||||||||
FaxNumber: | 5176472473 | ||||||||
Practice Location | |||||||||
Address1: | 406 KENT ST | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | MI | ||||||||
PostalCode: | 488751707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5176474166 | ||||||||
FaxNumber: | 5176472473 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2006 | ||||||||
LastUpdateDate: | 10/08/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301070253 | MI | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1008612 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 200000002664 | 01 | MI | PHP FAMILYCARE | OTHER | 200000002664 | 01 | MI | PHP | OTHER | 7182486 | 01 | MI | AETNA | OTHER | 4522012 | 05 | MI |   | MEDICAID | 0803400412 | 01 | MI | BCBS/BCN | OTHER | 0M21440028 | 01 | MI | MEDICARE ADVANTAGE | OTHER | 1008612 | 01 | MI | MCLAREN HEALTH PLAN-COMMERCIAL | OTHER | P00053237 | 01 | MI | RAILROAD MEDICARE | OTHER | 1008612 | 01 | MI | MCLAREN HEALTH PLAN-MEDICAID | OTHER |