Provider Demographics
NPI:1528252251
Name:PORT HURON INTERNAL MEDICINE ASSOCIATES
Entity type:Organization
Organization Name:PORT HURON INTERNAL MEDICINE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:I
Authorized Official - Last Name:JARAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-987-1000
Mailing Address - Street 1:2540 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-6405
Mailing Address - Country:US
Mailing Address - Phone:810-987-1000
Mailing Address - Fax:810-982-1810
Practice Address - Street 1:2540 16TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6405
Practice Address - Country:US
Practice Address - Phone:810-987-1000
Practice Address - Fax:810-982-1810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076169207R00000X
MI4301066771207Q00000X
MI4301095172207R00000X
MI4301061093207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G41221OtherBCBSM
MI34108OtherHEALTH PLAN OF MICHIGAN
MIDG3605OtherRAILROAD MEDICARE PIN
MIDG3605OtherRAILROAD MEDICARE PIN
MI1417675OtherUNITED HEALTH CARE
MI4152744Medicaid
MI110196407OtherRAILROAD MEDICARE PIN
MI1107401082OtherMEDICARE PLUS BLUE
MIG35455OtherHAP/CIGNA
MI900040508OtherPRIORITY HEALTH
MI103538OtherGREAT LAKES MEDICAID
MI109315OtherCARE CHOICES
MI1107401082OtherBCBSM
MI0P22570Medicare PIN
MI105910404081OtherHUMANA
MIG35455OtherALLIANCE HEALTH PLAN
MI2366756OtherAETNA MEDICARE ADVANTAGE