Healthcare Provider Details

I. General information

NPI: 1881908671
Provider Name (Legal Business Name): DR. RUSSELL FREDERICK LABEAU JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 ROLLING HILLS LN
PETOSKEY MI
49770-9602
US

IV. Provider business mailing address

402 ROLLING HILLS LN
PETOSKEY MI
49770-9602
US

V. Phone/Fax

Practice location:
  • Phone: 231-347-5682
  • Fax: 231-347-5682
Mailing address:
  • Phone: 231-347-5682
  • Fax: 231-347-5682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301026523
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: