Provider Demographics
NPI:1912903212
Name:MOUNTAIN TOWN FAMILY PRACTICE
Entity type:Organization
Organization Name:MOUNTAIN TOWN FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:CORBIN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:989-779-9089
Mailing Address - Street 1:308 W MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2410
Mailing Address - Country:US
Mailing Address - Phone:989-779-9089
Mailing Address - Fax:989-779-9269
Practice Address - Street 1:308 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2410
Practice Address - Country:US
Practice Address - Phone:989-779-9089
Practice Address - Fax:989-779-9269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002173363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty