Provider Demographics
NPI:1154645901
Name:JOSPEH R YACISEN DO PC
Entity type:Organization
Organization Name:JOSPEH R YACISEN DO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:YACISEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:989-466-2663
Mailing Address - Street 1:315 E WARWICK DR
Mailing Address - Street 2:STE B
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1083
Mailing Address - Country:US
Mailing Address - Phone:989-466-2663
Mailing Address - Fax:989-466-4748
Practice Address - Street 1:602 BEECH ST
Practice Address - Street 2:STE 1200
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1466
Practice Address - Country:US
Practice Address - Phone:989-802-5080
Practice Address - Fax:989-802-5090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJY012516207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4926111/11Medicaid
MIJY012516OtherLICENSE
MI4926111/11Medicaid
MIH74481Medicare UPIN
MIP16050001Medicare PIN