Healthcare Provider Details

I. General information

NPI: 1528252251
Provider Name (Legal Business Name): PORT HURON INTERNAL MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 16TH ST
PORT HURON MI
48060-6405
US

IV. Provider business mailing address

2540 16TH ST
PORT HURON MI
48060-6405
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-1000
  • Fax: 810-982-1810
Mailing address:
  • Phone: 810-987-1000
  • Fax: 810-982-1810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301066771
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301076169
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301095172
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301061093
License Number StateMI

VIII. Authorized Official

Name: JOHN I JARAD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 810-987-1000