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General NPI Number Information
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NPI Number | 1851580815
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Entity Type | Organization
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Legal Business Name | SOUTHERN GRAND TRAVERSE MEDICAL
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Dates
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Enumeration Date | 10/16/2007
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Last Update Date | 10/16/2007
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Provider Practice Location Address
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Address Line | 401 MUNSON AVE
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City | TRAVERSE CITY
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State | MI
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Zip | 49686-3041
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Country | US
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Telephone | 231-995-4902
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Fax | 231-932-7816
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Provider Business Mailing Address
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Address Line | 401 MUNSON AVE
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City | TRAVERSE CITY
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State | MI
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Zip | 49686-3041
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Country | US
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Telephone | 231-995-4902
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Fax | 231-932-7816
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Authorized Official
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Title or Position | OWNER
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Name | GARY J SCHAUB
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Credential | PA-C
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Telephone | 231-995-4902
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5601001376
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License Number State | MI
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