Provider Demographics
NPI:1801150453
Name:INTERNAL MEDICINE OF NORTHERN MICHIGAN LABORATORY
Entity type:Organization
Organization Name:INTERNAL MEDICINE OF NORTHERN MICHIGAN LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-487-9759
Mailing Address - Street 1:560 W MITCHELL ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2275
Mailing Address - Country:US
Mailing Address - Phone:231-487-2460
Mailing Address - Fax:231-487-6596
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2275
Practice Address - Country:US
Practice Address - Phone:231-487-2460
Practice Address - Fax:231-487-6596
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERNAL MEDICINE OF NORTHERN MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B40023OtherBCBSM