MEDICARE: WEST BRANCH PULMONARY CLINIC PC

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	261QS1200X	Sleep Disorder Diagnostic Clinic/Center
2	174400000X	Specialist	TM0009037	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
7	110216075	OTHER	MI	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1007603	OTHER	MI	MCLAREN HEALTH PLAN
2	115651012	OTHER	MI	BLUE CROSS BLUE SHIELD M
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	4509887	OTHER	MI	AETNA
5	1007603	OTHER	MI	MCLAREN HEALTH ADVANTAGE
6	122278	OTHER	MI	PREFERRED CHOICE PPO
8	115651012	OTHER	MI	BLUE CARE NETWORK
9	1679561443	OTHER	MI	NPI
10	54 0 F5 10350	OTHER	MI	BLUE CROSS BLUE SHIELD DM

General Provider Information

NPI Number	:	1790894988
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST BRANCH PULMONARY CLINIC PC

Provider Business Mailing Address
First Line	:	780 N GAVORD RD
Second Line	:
City	:	STERLING
State	:	MI
Zip	:	48659-9703
Country	:	US
Telephone Number	:	989-654-2168
Fax Number	:	989-654-2825

Provider Business Practice Location Address
First Line	:	780 N GAVORD RD
Second Line	:
City	:	STERLING
State	:	MI
Zip	:	48659-9703
Country	:	US
Telephone Number	:	989-654-2168
Fax Number	:	989-654-2825

Authorized Official
Title or Position	:	INSURANCE BILLER
Name	:	MS. VICKI LYNN HERRICK
Credential	:
Telephone Number	:	810-564-9270

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	01/05/2012

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