Healthcare Provider Details

I. General information

NPI: 1225547383
Provider Name (Legal Business Name): FRANKENMUTH MEDICAL ASSOCIATES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 S MAIN ST STE 6
FRANKENMUTH MI
48734-1692
US

IV. Provider business mailing address

PO BOX 22559
BELFAST ME
04915-4474
US

V. Phone/Fax

Practice location:
  • Phone: 989-502-1122
  • Fax: 989-502-1212
Mailing address:
  • Phone: 989-502-1122
  • Fax: 844-674-2260

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 Code363A00000X
TaxonomyPhysician Assistant
License Number5601006225
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LAUREN SURROCK
Title or Position: CEO
Credential: PA-C
Phone: 989-502-1122