=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801150453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNAL MEDICINE OF NORTHERN MICHIGAN LABORATORY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2012
-----------------------------------------------------
Last Update Date | 06/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 560 W MITCHELL ST SUITE 300
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-2275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-487-2460
-----------------------------------------------------
Fax | 231-487-6596
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 560 W MITCHELL ST SUITE 300
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-2275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-487-2460
-----------------------------------------------------
Fax | 231-487-6596
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | MR. ROBERT FARRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-487-9759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------