Basic Information
| Provider Information | |||||||||
| NPI: | 1780803932 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHRIDGE FAMILY PRACTICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 279 | ||||||||
| Address2: | |||||||||
| City: | HALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487390279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1989728600 | ||||||||
| FaxNumber: | 9897286003 | ||||||||
| Practice Location | |||||||||
| Address1: | 3190 NORTHRIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | HALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487399276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897286000 | ||||||||
| FaxNumber: | 9897286003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | PROVOAST | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9897286000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301061417 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0001X | 5101011670 | MI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | MA061417 | 01 | MI | MOHAMED ALI | OTHER | DL074550 | 01 | MI | DANIEL LEE | OTHER | 104289418 | 05 | MI | MEDICAID | 114811801 | 05 | MI | MEDICAID | 080C510310 | 01 | MI | BCBS GROUP | OTHER |