MEDICARE: RONALD MAX MINGLE PAC

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	363A00000X	Physician Assistant	5601001143	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0853713260	OTHER	MI	BCBSM

General Provider Information

NPI Number	:	1881772861
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD MAX MINGLE PAC

Provider Business Mailing Address
First Line	:	PO BOX 994
Second Line	:
City	:	ALMA
State	:	MI
Zip	:	48801-0994
Country	:	US
Telephone Number	:	989-463-0104
Fax Number	:	989-463-0663

Provider Business Practice Location Address
First Line	:	1621 E BROOMFIELD ST
Second Line	:	SUITE B
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-5427
Country	:	US
Telephone Number	:	989-772-1442
Fax Number	:	989-772-0735

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/25/2009

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