Provider Demographics
NPI:1548433360
Name:RONALD P D'AGOSTINO DO PC
Entity type:Organization
Organization Name:RONALD P D'AGOSTINO DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:P
Authorized Official - Last Name:D'AGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:906-524-7121
Mailing Address - Street 1:108 W EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-1214
Mailing Address - Country:US
Mailing Address - Phone:906-524-7121
Mailing Address - Fax:906-524-6014
Practice Address - Street 1:108 W EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-1214
Practice Address - Country:US
Practice Address - Phone:906-524-6366
Practice Address - Fax:906-524-6014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4137523Medicaid
MI150700025OtherBCBS RENDERING ID
BD6670207OtherDEA
BD6670207OtherDEA