MEDICARE: ALLEGIANCE HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	207Q00000X	MI

General Provider Information

NPI Number	:	1417395997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLEGIANCE HEALTH

Provider Business Mailing Address
First Line	:	1404 W. NORTH STREET
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202
Country	:	US
Telephone Number	:	517-782-2555
Fax Number	:

Provider Business Practice Location Address
First Line	:	1362 HEATHERWOOD LN
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48108-2813
Country	:	US
Telephone Number	:	405-408-6500
Fax Number	:

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	MR. LANCE DAVID MUEGGENBORG
Credential	:	FNP-BC
Telephone Number	:	405-408-6500

Provider Enumeration Date	:	06/06/2013
Last Update Date	:	07/29/2013

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