Provider Demographics
NPI:1538251756
Name:VAN DER HARST, CAROL (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:VAN DER HARST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-2478
Mailing Address - Country:US
Mailing Address - Phone:989-667-4230
Mailing Address - Fax:989-667-4546
Practice Address - Street 1:903 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2478
Practice Address - Country:US
Practice Address - Phone:989-667-4230
Practice Address - Fax:989-667-4546
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407223208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6V42615OtherHEALTHPLUS
MI3069287Medicaid
MI71020000098824OtherBLUE CROSS BLUE SHIELD
F10124Medicare UPIN
MI3069287Medicaid