1245445972 NPI number — PHYSICIAN HEALTHCARE NETWORK, PC

Table of content: MISS STACY MARIE OLIVER M.ED (NPI 1083973515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245445972 NPI number — PHYSICIAN HEALTHCARE NETWORK, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN HEALTHCARE NETWORK, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245445972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3050 COMMERCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT GRATIOT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48059-3819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-385-4441
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 MILITARY ST BLDG 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-6692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-984-5700
Provider Business Practice Location Address Fax Number:
810-984-1886
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CUSUMANO
Authorized Official First Name:
MIMMA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
810-385-8081

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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