Provider Demographics
NPI:1134393481
Name:PHILLIP W. NIEMI, D.O.,P.C.
Entity type:Organization
Organization Name:PHILLIP W. NIEMI, D.O.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:W
Authorized Official - Last Name:NIEMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-632-1100
Mailing Address - Street 1:550 OSBORN BLVD
Mailing Address - Street 2:SUITE #202
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1899
Mailing Address - Country:US
Mailing Address - Phone:906-632-1100
Mailing Address - Fax:906-632-7768
Practice Address - Street 1:550 OSBORN BLVD
Practice Address - Street 2:SUITE #202
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1899
Practice Address - Country:US
Practice Address - Phone:906-632-1100
Practice Address - Fax:906-632-7768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2120652Medicaid
MIE26499Medicare UPIN