Provider Demographics
NPI:1912087685
Name:MANITOU MEDICAL CENTER
Entity type:Organization
Organization Name:MANITOU MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-352-7103
Mailing Address - Street 1:9975 W OTTAWA AVE
Mailing Address - Street 2:
Mailing Address - City:EMPIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49630-9618
Mailing Address - Country:US
Mailing Address - Phone:231-326-2300
Mailing Address - Fax:231-326-2302
Practice Address - Street 1:9975 W OTTAWA AVE
Practice Address - Street 2:
Practice Address - City:EMPIRE
Practice Address - State:MI
Practice Address - Zip Code:49630-9618
Practice Address - Country:US
Practice Address - Phone:231-326-2300
Practice Address - Fax:231-326-2302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty