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General NPI Number Information
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NPI Number | 1972658136
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Entity Type | Organization
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Legal Business Name | PRIMARY CARE SPORTS MEDICINE PC
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 07/08/2008
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Provider Practice Location Address
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Address Line | 560 W MITCHELL ST SUITE 340
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City | PETOSKEY
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State | MI
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Zip | 49770-2275
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Country | US
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Telephone | 231-348-9710
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Fax | 231-348-9715
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Provider Business Mailing Address
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Address Line | 560 W MITCHELL ST SUITE 340
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City | PETOSKEY
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State | MI
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Zip | 49770-2275
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Country | US
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Telephone | 231-348-9710
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Fax | 231-348-9715
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TODD M SHEPERD
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Credential | MD
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Telephone | 231-348-9710
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301074786
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License Number State | MI
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