MEDICARE: PHILLIP W SIEMER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	PS051573	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	700D510020	OTHER	MI	BLUE CARE NETWORK
4	700D510020	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1588612972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP W SIEMER MD

Provider Business Mailing Address
First Line	:	PO BOX 397
Second Line	:
City	:	SUTTONS BAY
State	:	MI
Zip	:	49682-0397
Country	:	US
Telephone Number	:	231-271-5990
Fax Number	:	231-271-5959

Provider Business Practice Location Address
First Line	:	93 W FOURTH ST STE C
Second Line	:
City	:	SUTTONS BAY
State	:	MI
Zip	:	49682-8408
Country	:	US
Telephone Number	:	231-271-5990
Fax Number	:	231-271-5959

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	03/10/2020

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