Basic Information
| Provider Information | |||||||||
| NPI: | 1366888448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOMB | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | CHILMAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHILMAN | ||||||||
| OtherFirstName: | MINDY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 S HAGADORN RD STE 500 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488236804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174326144 | ||||||||
| FaxNumber: | 5174326150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2013 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101020312 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 204D00000X | 5101020312 | MI | Y | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM |
No ID Information.