Basic Information
| Provider Information | |||||||||
| NPI: | 1649291873 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN HEART & VASCULAR SPECIALISTS, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PETOSKEY CARDIOLOGY, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872490 | ||||||||
| FaxNumber: | 2314876055 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872490 | ||||||||
| FaxNumber: | 2314876055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 09/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | NOBLETT | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2314879807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BSN, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | G05370 | 01 | MI | BLUE CARE NETWORK | OTHER | OB41013 | 01 | MI | BLUE SHIELD | OTHER |