MEDICARE: MRS. THERESA LARSEN M.D.

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	207R00000X	Internal Medicine Physician	4301407146	MI
2	208000000X	Pediatrics Physician	4301407146	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477551166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA LARSEN M.D.

Provider Business Mailing Address
First Line	:	1375 S LAPEER RD
Second Line	:	STE 210
City	:	LAKE ORION
State	:	MI
Zip	:	48360-1421
Country	:	US
Telephone Number	:	248-693-5700
Fax Number	:	248-693-5715

Provider Business Practice Location Address
First Line	:	1375 S LAPEER RD
Second Line	:	STE 210
City	:	LAKE ORION
State	:	MI
Zip	:	48360-1421
Country	:	US
Telephone Number	:	248-693-5700
Fax Number	:	248-693-5715

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	10/03/2013

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