Provider Demographics
NPI:1720269814
Name:CEDAR RUN FAMILY MEDICINE CENTER
Entity type:Organization
Organization Name:CEDAR RUN FAMILY MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LASKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-916-2024
Mailing Address - Street 1:520 S WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:MANCELONA
Mailing Address - State:MI
Mailing Address - Zip Code:49659-9701
Mailing Address - Country:US
Mailing Address - Phone:231-916-2024
Mailing Address - Fax:231-916-2028
Practice Address - Street 1:520 S WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:MANCELONA
Practice Address - State:MI
Practice Address - Zip Code:49659-9701
Practice Address - Country:US
Practice Address - Phone:231-916-2024
Practice Address - Fax:231-916-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4748889Medicaid