Healthcare Provider Details

I. General information

NPI: 1174577720
Provider Name (Legal Business Name): ALPINE FAMILY MEDICINE PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 N OTSEGO AVE
GAYLORD MI
49735-2502
US

IV. Provider business mailing address

652 N OTSEGO AVE
GAYLORD MI
49735-2502
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-3529
  • Fax: 989-732-7865
Mailing address:
  • Phone: 989-732-3529
  • Fax: 989-732-7865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberKK030249
License Number StateMI

VIII. Authorized Official

Name: DR. DEREK DAVID OLSON
Title or Position: MD/OWNER
Credential: MD
Phone: 989-732-3529