Provider Demographics
NPI:1063713238
Name:CEDAR STREET FAMILY MEDICINE PC
Entity type:Organization
Organization Name:CEDAR STREET FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORRINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-244-1000
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854
Mailing Address - Country:US
Mailing Address - Phone:517-244-1000
Mailing Address - Fax:517-244-1030
Practice Address - Street 1:806 HOGSBACK RD
Practice Address - Street 2:SUITE C
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-9569
Practice Address - Country:US
Practice Address - Phone:517-244-1000
Practice Address - Fax:517-244-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH27641Medicare UPIN