Healthcare Provider Details

I. General information

NPI: 1750744066
Provider Name (Legal Business Name): INTEGRATIVE SPECIALTY CARE OF NORTHERN MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 WOODS WAY
PETOSKEY MI
49770-7628
US

IV. Provider business mailing address

3250 WOODS WAY
PETOSKEY MI
49770-7628
US

V. Phone/Fax

Practice location:
  • Phone: 231-348-3800
  • Fax: 877-397-7480
Mailing address:
  • Phone: 231-348-3800
  • Fax: 877-397-7480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301041105
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number4301041105
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number4301041254
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301041254
License Number StateMI

VIII. Authorized Official

Name: IRENE KAZMERS
Title or Position: CO-OWNER
Credential: MD
Phone: 231-348-3800