Healthcare Provider Details

I. General information

NPI: 1225270002
Provider Name (Legal Business Name): WEST BRANCH FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 COURT STREET
WEST BRANCH MI
48661-0903
US

IV. Provider business mailing address

959 WEST M-61
STANDISH MI
48658-9307
US

V. Phone/Fax

Practice location:
  • Phone: 989-516-4317
  • Fax: 989-345-5803
Mailing address:
  • Phone: 989-516-4317
  • Fax: 989-345-5803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101013179
License Number StateMI

VIII. Authorized Official

Name: JOHN C URBAN
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 989-516-4317