Basic Information
| Provider Information | |||||||||
| NPI: | 1801150453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MEDICINE OF NORTHERN MICHIGAN LABORATORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872460 | ||||||||
| FaxNumber: | 2314876596 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872460 | ||||||||
| FaxNumber: | 2314876596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2012 | ||||||||
| LastUpdateDate: | 06/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2314879759 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTERNAL MEDICINE OF NORTHERN MICHIGAN | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0B40023 | 01 | MI | BCBSM | OTHER |