Healthcare Provider Details

I. General information

NPI: 1558483362
Provider Name (Legal Business Name): GRAND TRAVERSE WOMENS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 SIXTH ST STE 400
TRAVERSE CITY MI
49684-2369
US

IV. Provider business mailing address

1200 SIXTH ST STE 400
TRAVERSE CITY MI
49684-2369
US

V. Phone/Fax

Practice location:
  • Phone: 231-392-0650
  • Fax: 231-392-0665
Mailing address:
  • Phone: 231-392-0650
  • Fax: 231-392-0665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number4704127539
License Number StateMI

VIII. Authorized Official

Name: JANICE LYNN MCALLISTER
Title or Position: MIDWIFE
Credential: CNM
Phone: 231-392-0650