Healthcare Provider Details

I. General information

NPI: 1396609467
Provider Name (Legal Business Name): BIRCH SHORE PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 SCHOEDEL RD
MANISTEE MI
49660-9753
US

IV. Provider business mailing address

3021 SCHOEDEL RD
MANISTEE MI
49660-9753
US

V. Phone/Fax

Practice location:
  • Phone: 231-397-9229
  • Fax:
Mailing address:
  • Phone: 231-397-9229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES JAY VANDENBERG IV
Title or Position: PRESIDENT
Credential: D.O.
Phone: 660-988-0795