Healthcare Provider Details

I. General information

NPI: 1639314735
Provider Name (Legal Business Name): PINE MEDICAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W PINE LAKE DR
NEWAYGO MI
49337-8029
US

IV. Provider business mailing address

230 W OAK ST
FREMONT MI
49412-1526
US

V. Phone/Fax

Practice location:
  • Phone: 231-652-1631
  • Fax: 231-652-1733
Mailing address:
  • Phone: 231-924-4200
  • Fax: 231-924-4064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateMI

VIII. Authorized Official

Name: MRS. MARGE YOUNG
Title or Position: ADMINISTRATOR
Credential:
Phone: 231-924-4200