Healthcare Provider Details

I. General information

NPI: 1437163409
Provider Name (Legal Business Name): PORT HURON MERCY FAMILY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 24TH AVE SUITE 206
FORT GRATIOT MI
48059-3882
US

IV. Provider business mailing address

PO BOX 610669
PORT HURON MI
48061-0669
US

V. Phone/Fax

Practice location:
  • Phone: 810-216-4000
  • Fax: 810-216-4001
Mailing address:
  • Phone: 810-985-1884
  • Fax: 810-966-3025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NANCY MASON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 810-985-1884