Healthcare Provider Details

I. General information

NPI: 1598141640
Provider Name (Legal Business Name): PORT HURON PHYSICIANS MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
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 638928
CINCINNATI OH
45263-0669
US

V. Phone/Fax

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

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 Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JULIE ANN BROWN-MCCOY
Title or Position: CBO MANAGER
Credential:
Phone: 810-216-2902