Basic Information
| Provider Information | |||||||||
| NPI: | 1861628430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONDIE | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | CLYDE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD # A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173534911 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 S HAGADORN RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488236804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178848701 | ||||||||
| FaxNumber: | 5178848787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2009 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 362864-1204 | UT | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 5101018410 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1861528430 | 05 | MI | MEDICAID |