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General NPI Number Information
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NPI Number | 1841357464
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Entity Type | Organization
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Legal Business Name | NORTHSHORE MEDICAL CLINIC P C
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 12/19/2008
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Provider Practice Location Address
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Address Line | 7786 MULLETT LAKE RD
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City | CHEBOYGAN
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State | MI
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Zip | 49721-9056
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Country | US
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Telephone | 231-627-2869
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Fax | 231-627-2869
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Provider Business Mailing Address
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Address Line | 7786 MULLETT LAKE RD
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City | CHEBOYGAN
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State | MI
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Zip | 49721-9056
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Country | US
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Telephone | 231-627-2869
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Fax | 231-627-2869
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. JEROME E SIUDARA
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Credential | D.O.
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Telephone | 231-627-2869
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 5101005875
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License Number State | MI
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