Basic Information
| Provider Information | |||||||||
| NPI: | 1821031519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUTSATSON | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2853 HEALTH PKWY STE A | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488589375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897795222 | ||||||||
| FaxNumber: | 9899535153 | ||||||||
| Practice Location | |||||||||
| Address1: | 2853 HEALTH PKWY STE A | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488589375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897795222 | ||||||||
| FaxNumber: | 9899535153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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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 | 5101014853 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.