Basic Information
| Provider Information | |||||||||
| NPI: | 1992884969 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1485 S. M-139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699250585 | ||||||||
| FaxNumber: | 2699250070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1485 S. M-139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699250585 | ||||||||
| FaxNumber: | 2699250070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301077450 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 4303750 | 05 | MI | MEDICAID |