Provider Demographics
NPI:1174526594
Name:THUNDER BAY EMERGENCY PHYSICIANS PC
Entity type:Organization
Organization Name:THUNDER BAY EMERGENCY PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD OF THE GROUP
Authorized Official - Prefix:
Authorized Official - First Name:BEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:800-968-6866
Mailing Address - Street 1:PO BOX 2347
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-2347
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:616-532-7230
Practice Address - Street 1:1501 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1401
Practice Address - Country:US
Practice Address - Phone:800-968-6866
Practice Address - Fax:616-532-7230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5010009914207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICI7552OtherRAILROAD MEDICARE GROUP
MI0M60540Medicare ID - Type Unspecified