Basic Information
| Provider Information | |||||||||
| NPI: | 1659387488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRATIOT FAMILY PRACTICE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 E WARWICK DR | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488011010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894633101 | ||||||||
| FaxNumber: | 9894632824 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E WARWICK DR | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488011010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894633101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 06/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | CHESSIN | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL PHYSCIAN | ||||||||
| AuthorizedOfficialTelephone: | 9894633101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3822220235 | MI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1318641 | 05 | MI | MEDICAID | 2772212 | 05 | MI | MEDICAID | 1336031 | 05 | MI | MEDICAID | 4600404 | 05 | MI | MEDICAID |