Healthcare Provider Details

I. General information

NPI: 1225205438
Provider Name (Legal Business Name): ARTESIAN SPRINGS MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E MAIN ST
MARION MI
49665-9642
US

IV. Provider business mailing address

100 E MAIN ST PO BOX 578
MARION MI
49665-9642
US

V. Phone/Fax

Practice location:
  • Phone: 231-743-0150
  • Fax: 231-743-0152
Mailing address:
  • Phone: 231-743-0150
  • Fax: 231-743-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003629
License Number StateMI

VIII. Authorized Official

Name: TRICIA ANN MCGILLIS
Title or Position: SOLE PROPRIETOR
Credential: PA-C, MPAS
Phone: 231-743-0150