Basic Information
| Provider Information | |||||||||
| NPI: | 1780620070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LICHT | ||||||||
| FirstName: | KARRIN | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6514 | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496966514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893401211 | ||||||||
| FaxNumber: | 9893401214 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 W CHISHOLM ST | ||||||||
| Address2: | |||||||||
| City: | ALPENA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497071401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893401211 | ||||||||
| FaxNumber: | 9893491214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301073974 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 4301073974 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4529425 | 05 | MI | MEDICAID |