Healthcare Provider Details

I. General information

NPI: 1013413236
Provider Name (Legal Business Name): SPORTS AND REGENERATIVE MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 W GENESEE ST
FRANKENMUTH MI
48734-1305
US

IV. Provider business mailing address

170 W GENESEE ST
FRANKENMUTH MI
48734-1305
US

V. Phone/Fax

Practice location:
  • Phone: 989-652-7344
  • Fax: 989-652-7355
Mailing address:
  • Phone: 989-652-7344
  • Fax: 989-652-7355

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 Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GAELEN AUGUST RAND
Title or Position: BILLING SPECIALIST
Credential:
Phone: 989-652-7344