Healthcare Provider Details

I. General information

NPI: 1275509036
Provider Name (Legal Business Name): TAWAS BAY FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 W LAKE ST
TAWAS CITY MI
48763-5105
US

IV. Provider business mailing address

PO BOX 369
TAWAS CITY MI
48764-0369
US

V. Phone/Fax

Practice location:
  • Phone: 989-362-3447
  • Fax:
Mailing address:
  • Phone: 989-362-3447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301033122
License Number StateMI

VIII. Authorized Official

Name: MS. SUZANNE HEILIG
Title or Position: MA
Credential:
Phone: 989-362-5688