Basic Information
| Provider Information | |||||||||
| NPI: | 1881691095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOULL | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872460 | ||||||||
| FaxNumber: | 2314876596 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872460 | ||||||||
| FaxNumber: | 2314876596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 4301059135 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 104116695 | 05 | MI | MEDICAID |