=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558616144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GERIATRIC PHYSICIAN STAFFING PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2012
-----------------------------------------------------
Last Update Date | 07/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 W FOURTH ST
-----------------------------------------------------
City | SUTTONS BAY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49682-9733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-271-1200
-----------------------------------------------------
Fax | 231-271-5959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 N SETTERBO RD
-----------------------------------------------------
City | SUTTONS BAY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49682-9391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-271-5990
-----------------------------------------------------
Fax | 231-271-5959
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. PHILLIP W SIEMER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 231-271-5990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4301051573
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 4301051573
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------