Healthcare Provider Details

I. General information

NPI: 1336409192
Provider Name (Legal Business Name): BLUE WATER MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 FORT ST SUITE 102
PORT HURON MI
48060-3922
US

IV. Provider business mailing address

511 FORT ST SUITE 102
PORT HURON MI
48060-3922
US

V. Phone/Fax

Practice location:
  • Phone: 810-479-4769
  • Fax: 888-414-4545
Mailing address:
  • Phone: 810-479-4769
  • Fax: 888-414-4545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number4301093347
License Number StateMI

VIII. Authorized Official

Name: DR. MARCUS K. FREE
Title or Position: PRESIDENT/MEMBER
Credential: M.D.
Phone: 810-479-4769