Healthcare Provider Details

I. General information

NPI: 1396798682
Provider Name (Legal Business Name): OTHER OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 US 31 S
TRAVERSE CITY MI
49684-4495
US

IV. Provider business mailing address

3074 N US 31 S
TRAVERSE CITY MI
49684-4533
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0500
  • Fax: 231-935-0501
Mailing address:
  • Phone: 231-929-1234
  • Fax: 231-935-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER W SPRINGSTEEN
Title or Position: PRESIDENT
Credential: MD
Phone: 231-929-1234