Provider Demographics
NPI:1316145972
Name:ADVANTAGE HEALTH CLINIC, FOR MEN, INC
Entity type:Organization
Organization Name:ADVANTAGE HEALTH CLINIC, FOR MEN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:IGNATOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-789-1900
Mailing Address - Street 1:18625 CENTENNIAL RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9372
Mailing Address - Country:US
Mailing Address - Phone:269-789-1900
Mailing Address - Fax:269-789-1974
Practice Address - Street 1:18625 CENTENNIAL RD
Practice Address - Street 2:SUITE D
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-9372
Practice Address - Country:US
Practice Address - Phone:269-789-1900
Practice Address - Fax:269-789-1974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301033625207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1952416877OtherINDIVIDUAL NPI
MI4301055180OtherSTE LICENSE NUMBER
MIF05571OtherUPIN
MI1043379530OtherNPI INDIVIDUAL
MI3522410Medicaid
MI1316145972OtherGROUP NPI
MI1952416877OtherNPI
MIG05602OtherUPIN
MI1101312522OtherWULFBCINDPIN
MICR033625OtherMICHIGAN LICENSE NUMBER
MI4301055180OtherLICENSE NUMBER
MI700A310290OtherBLUE CROSS BLUE SHIELD
MI1952416877OtherNPI
MI0M49480005Medicare PIN