Healthcare Provider Details

I. General information

NPI: 1649214099
Provider Name (Legal Business Name): UPPER MICHIGAN CARDIOVASCULAR ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 WEST FAIR AVE SUITE 334
MARQUETTE MI
49855
US

IV. Provider business mailing address

1414 WEST FAIR AVE SUITE 334
MARQUETTE MI
49855
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-3870
  • Fax: 906-225-4861
Mailing address:
  • Phone: 906-225-3870
  • Fax: 906-225-4861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS DALE LEGALLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 906-225-3870