Basic Information
| Provider Information | |||||||||
| NPI: | 1811997463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICHT | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9900 BIRCH RUN RD | ||||||||
| Address2: | |||||||||
| City: | BIRCH RUN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484159609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896241500 | ||||||||
| FaxNumber: | 9896241506 | ||||||||
| Practice Location | |||||||||
| Address1: | 9900 BIRCH RUN RD | ||||||||
| Address2: | |||||||||
| City: | BIRCH RUN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484159609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896241500 | ||||||||
| FaxNumber: | 9896241506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 010453 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4506206 | 05 | MI | MEDICAID | OG31024 | 01 | MI | BCN | OTHER | 0G310240 | 01 | MI | BCBS | OTHER | 080110138 | 01 | MI | RR MEDICARE | OTHER | 0150900525 | 01 | MA | HEALTHPLUS | OTHER | 4219244 | 01 | MH | AETNA | OTHER |