=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932994217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIC OF MICHIGAN, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2025
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4290 COPPER RIDGE DR STE 130
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-7205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-252-0893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4290 COPPER RIDGE DR STE 130
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-7205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-252-0893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSH VANDER LUGT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-366-5079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 209800000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine (M.D./D.O.) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------