Healthcare Provider Details

I. General information

NPI: 1558616144
Provider Name (Legal Business Name): GERIATRIC PHYSICIAN STAFFING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W FOURTH ST
SUTTONS BAY MI
49682-9733
US

IV. Provider business mailing address

2700 N SETTERBO RD
SUTTONS BAY MI
49682-9391
US

V. Phone/Fax

Practice location:
  • Phone: 231-271-1200
  • Fax: 231-271-5959
Mailing address:
  • Phone: 231-271-5990
  • Fax: 231-271-5959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4301051573
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301051573
License Number StateMI

VIII. Authorized Official

Name: DR. PHILLIP W SIEMER
Title or Position: PHYSICIAN
Credential: MD
Phone: 231-271-5990