Basic Information
| Provider Information | |||||||||
| NPI: | 1750334405 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN HEALTHCARE NETWORK, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 COMMERCE DR | ||||||||
| Address2: | BILLING AND ADMINISTRATION | ||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103854441 | ||||||||
| FaxNumber: | 8103851540 | ||||||||
| Practice Location | |||||||||
| Address1: | 3350 GRATIOT BLVD | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480402121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103644000 | ||||||||
| FaxNumber: | 8103645995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | CUSUMANO | ||||||||
| AuthorizedOfficialFirstName: | MIMMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8103858081 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RI0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 291U00000X | 23D0364244 | MI | N | Laboratories | Clinical Medical Laboratory | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1750334405 | 05 | MI | MEDICAID |