Provider Demographics
NPI:1538670518
Name:LUNG DOCS OF AMERICA, PLLC
Entity type:Organization
Organization Name:LUNG DOCS OF AMERICA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HUISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:810-990-8222
Mailing Address - Street 1:2615 ELECTRIC AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6575
Mailing Address - Country:US
Mailing Address - Phone:810-990-8222
Mailing Address - Fax:810-937-5592
Practice Address - Street 1:1210 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3406
Practice Address - Country:US
Practice Address - Phone:810-984-8470
Practice Address - Fax:810-984-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430107244207RP1001X
MI4301055094207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4153017Medicaid