Healthcare Provider Details

I. General information

NPI: 1689623506
Provider Name (Legal Business Name): MYMICHIGAN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 WELLNESS DR
MIDLAND MI
48670
US

IV. Provider business mailing address

4000 WELLNESS DR
MIDLAND MI
48670-2000
US

V. Phone/Fax

Practice location:
  • Phone: 844-832-1956
  • Fax:
Mailing address:
  • Phone: 844-832-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARAH JAMES
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 989-701-4734