Provider Demographics
NPI:1528337094
Name:OKEMOS OSTEOPATHIC CENTER PLC
Entity type:Organization
Organization Name:OKEMOS OSTEOPATHIC CENTER PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-SOLE PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO, MS
Authorized Official - Phone:517-381-0299
Mailing Address - Street 1:2501 JOLLY ROAD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3676
Mailing Address - Country:US
Mailing Address - Phone:517-381-0299
Mailing Address - Fax:517-381-9950
Practice Address - Street 1:2501 JOLLY ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3676
Practice Address - Country:US
Practice Address - Phone:517-381-0299
Practice Address - Fax:517-381-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009343208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5330181Medicare Oscar/Certification
MIF09765Medicare UPIN
MIP00741078Medicare PIN