=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619093283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTRY DOCTOR FAMILY PRACTICE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 N LAPEER RD STE 101
-----------------------------------------------------
City | LAKE ORION
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48362-4011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-693-4500
-----------------------------------------------------
Fax | 248-693-8170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 N LAPEER RD STE 101
-----------------------------------------------------
City | LAKE ORION
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48362-4011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-693-4500
-----------------------------------------------------
Fax | 248-693-8170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISITNE SYPITKOWSKI
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 248-693-4500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101010326
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------