Basic Information
| Provider Information | |||||||||
| NPI: | 1841247525 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELK RAPIDS FAMILY PRACTICE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 124 AMES ST | ||||||||
| Address2: | |||||||||
| City: | ELK RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496299449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312648282 | ||||||||
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| Practice Location | |||||||||
| Address1: | 124 AMES ST | ||||||||
| Address2: | |||||||||
| City: | ELK RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496299449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312648282 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2312648282 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080Z510130 | 01 | MI | BCBS GROUP NUMBER | OTHER |