# NORTHRIDGE FAMILY PRACTICE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1780803932
- **Authorized official:** DEBRA PROVOAST NP (OWNER)
- **Authorized official phone:** (989) 728-6000

## Contact information

- **Practice address:** 3190 NORTHRIDGE DRIVE, HALE, MI 48739-9276
- **Practice address phone:** (989) 728-6000
- **Practice address fax:** (989) 728-6003
- **Mailing address:** PO BOX 279, HALE, MI 48739-0279
- **Mailing address phone:** (198) 972-8600
- **Mailing address fax:** (989) 728-6003

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 4301061417 | MI | — |
| 207RC0001X | Clinical Cardiac Electrophysiology Physician | 5101011670 | MI | Yes |

## Other

- **Enumeration date:** 04/25/2007
- **Last updated:** 01/13/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 080C510310 | BCBS GROUP | MI |
| 05 | — | 104289418 | — | MI |
| 05 | — | 114811801 | — | MI |
| 01 | — | DL074550 | DANIEL LEE | MI |
| 01 | — | MA061417 | MOHAMED ALI | MI |