Healthcare Provider Details

I. General information

NPI: 1760486260
Provider Name (Legal Business Name): DR. MICHAEL D COLBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 CEDAR RUN RD
TRAVERSE CITY MI
49684-9687
US

IV. Provider business mailing address

3930 CEDAR RUN RD
TRAVERSE CITY MI
49684-9687
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0390
  • Fax:
Mailing address:
  • Phone: 231-935-0390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301079215
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: