Healthcare Provider Details

I. General information

NPI: 1356551832
Provider Name (Legal Business Name): PINE MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 N DIVISION AVE
HESPERIA MI
49421
US

IV. Provider business mailing address

230 W OAK ST
FREMONT MI
49412-1575
US

V. Phone/Fax

Practice location:
  • Phone: 231-854-6415
  • Fax: 231-854-6975
Mailing address:
  • Phone: 231-924-4200
  • Fax: 231-924-2027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. HENRY WESTRA
Title or Position: ADMINISTRATOR
Credential:
Phone: 231-924-4200