Healthcare Provider Details

I. General information

NPI: 1467420901
Provider Name (Legal Business Name): INTERNAL MEDICINE OF NORTHERN MICHIGAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W MITCHELL ST SUITE 300
PETOSKEY MI
49770-2275
US

IV. Provider business mailing address

560 W MITCHELL ST SUITE 300
PETOSKEY MI
49770-2275
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-2460
  • Fax: 231-487-6596
Mailing address:
  • Phone: 231-487-2460
  • Fax: 231-487-6596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT E FARRELL
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 231-487-2460