Healthcare Provider Details

I. General information

NPI: 1467093153
Provider Name (Legal Business Name): APOLLO MEDICAL GROUP OF TRAVERSE CITY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3663 N COUNTRY DR
TRAVERSE CITY MI
49684-4587
US

IV. Provider business mailing address

PO BOX 4406
SPRINGFIELD IL
62708-4406
US

V. Phone/Fax

Practice location:
  • Phone: 866-888-8510
  • Fax:
Mailing address:
  • Phone: 866-888-8510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: ROBIN VAN SPRUNDEL
Title or Position: DIRECTOR OF ADMINISTRATION
Credential:
Phone: 941-725-1198