Organization
BLUE WATER INTERNAL MEDICINE, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NIKKI HACK (PRACTICE MANAGER)
(810) 662-3505
Entity
Organization
Contact information
Practice address
1210 10TH AVE, PORT HURON, MI 48060-3406
(810) 622-3505
(810) 662-3479
Mailing address
1210 10TH AVE, PORT HURON, MI 48060-3406
(810) 662-3505
(810) 662-3479
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4301076169
STATE MEDICAL LICENSE
MI
Enumeration date
03/17/2020
Last updated
11/18/2024
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