Basic Information
| Provider Information | |||||||||
| NPI: | 1891712493 | ||||||||
| 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: | 9897286000 | ||||||||
| FaxNumber: | 9897286003 | ||||||||
| Practice Location | |||||||||
| Address1: | 3190 NORTHRIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | HALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487399276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897286000 | ||||||||
| FaxNumber: | 9897286003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 11/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | PROVOAST | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | KAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9897286000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN MSN FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301061417 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | 4704148660 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 4704245250 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 4704283185 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 4704173663 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1017859 | 01 | MI | MCLAREN | OTHER | 105230710 | 05 | MI | MEDICAID | BW148660 | 01 | MI | BETH WEAVER LICENSE | OTHER | MA061417 | 01 | MOHAMED ALI | OTHER | RAILROAD MEDICARE | 01 | MI | P00261196 | OTHER | 4704283185 | 01 | MI | LINDSEY LICENSE | OTHER | 104289418 | 05 | MI | MEDICAID | 105235126 | 05 | MI | MEDICAID | OC51020 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 1017858 | 01 | MI | MCLAREN DEB PROVOAST | OTHER | DP173663 | 01 | MI | DEBBIE PROVOAST LICENSE | OTHER | DD9334 | 01 | MI | RAILROAD MEDICARE | OTHER |