Provider Demographics
NPI:1124052816
Name:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Entity type:Organization
Organization Name:LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-242-1700
Mailing Address - Street 1:7500 ODAWA CIR
Mailing Address - Street 2:ATTN: BILLING
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9692
Mailing Address - Country:US
Mailing Address - Phone:231-242-1611
Mailing Address - Fax:231-242-1730
Practice Address - Street 1:1250 LEARS RD.
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8774
Practice Address - Country:US
Practice Address - Phone:231-242-1700
Practice Address - Fax:231-242-1717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M96140Medicare ID - Type Unspecified
MI231872Medicare Oscar/Certification