MEDICARE: SIC OF MICHIGAN, 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	261QH0100X	Health Service Clinic/Center
2	209800000X	Legal Medicine (M.D./D.O.) Physician

General Provider Information

NPI Number	:	1932994217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIC OF MICHIGAN, PC

Provider Business Mailing Address
First Line	:	4290 COPPER RIDGE DR STE 130
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7205
Country	:	US
Telephone Number	:	231-252-0893
Fax Number	:

Provider Business Practice Location Address
First Line	:	4290 COPPER RIDGE DR STE 130
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7205
Country	:	US
Telephone Number	:	231-252-0893
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOSH VANDER LUGT
Credential	:
Telephone Number	:	616-366-5079

Provider Enumeration Date	:	04/09/2025
Last Update Date	:	04/09/2025

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