Healthcare Provider Details

I. General information

NPI: 1164695839
Provider Name (Legal Business Name): COUNTRYSIDE HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E MAIN ST STE A
MARION MI
49665-9642
US

IV. Provider business mailing address

PO BOX 1024
CADILLAC MI
49601-6024
US

V. Phone/Fax

Practice location:
  • Phone: 231-743-6002
  • Fax: 231-743-6081
Mailing address:
  • Phone: 231-775-6076
  • Fax: 231-775-0027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUE E DUNHAM
Title or Position: OWNER
Credential: FNP
Phone: 231-743-6002