Basic Information
Provider Information | |||||||||
NPI: | 1902999550 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | M. ELIZABETH SWENOR, DO, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2390 MITCHELL PARK DR | ||||||||
Address2: | UNIT D | ||||||||
City: | PETOSKEY | ||||||||
State: | MI | ||||||||
PostalCode: | 49770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2314879355 | ||||||||
FaxNumber: | 2314871737 | ||||||||
Practice Location | |||||||||
Address1: | 2390 MITCHELL PARK DR | ||||||||
Address2: | UNIT D | ||||||||
City: | PETOSKEY | ||||||||
State: | MI | ||||||||
PostalCode: | 49770 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2314879355 | ||||||||
FaxNumber: | 2314871737 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SWENOR | ||||||||
AuthorizedOfficialFirstName: | MARGARET | ||||||||
AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2314872340 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5315016050 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 4954920 | 05 | MI |   | MEDICAID |