Provider Demographics
NPI:1316103930
Name:TRAVERSE BAY MEDICAL
Entity type:Organization
Organization Name:TRAVERSE BAY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:LOUDER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:231-933-8805
Mailing Address - Street 1:207 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2347
Mailing Address - Country:US
Mailing Address - Phone:231-933-8805
Mailing Address - Fax:
Practice Address - Street 1:207 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2347
Practice Address - Country:US
Practice Address - Phone:231-933-8805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-03
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F98047Medicare UPIN