Healthcare Provider Details

I. General information

NPI: 1033253133
Provider Name (Legal Business Name): JOHN STREET CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E JOHN ST
LAKE CITY MI
49651
US

IV. Provider business mailing address

PO BOX 213
CADILLAC MI
49601-0213
US

V. Phone/Fax

Practice location:
  • Phone: 231-839-4359
  • Fax: 231-839-0223
Mailing address:
  • Phone: 231-775-6076
  • Fax: 231-775-0027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SOTERO M URETA
Title or Position: OWNER
Credential: M.D.
Phone: 231-839-4359