Healthcare Provider Details

I. General information

NPI: 1447262373
Provider Name (Legal Business Name): COUNTRYSIDE HEALTH CLNIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E MAIN STREET SUITE A
MARION MI
49665
US

IV. Provider business mailing address

PO BOX 1024
CADILLAC MI
49601-6024
US

V. Phone/Fax

Practice location:
  • Phone: 231-775-6076
  • Fax:
Mailing address:
  • Phone: 231-775-6076
  • Fax: 231-775-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRICIA A MCGILLIS
Title or Position: PRESIDENT
Credential: PAC
Phone: 231-775-6076