Organization
ADVANTAGE HEALTH CLINIC, FOR MEN, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LISA A IGNATOSKI (MANAGER)
(269) 789-1900
Entity
Organization
Contact information
Practice address
18625 CENTENNIAL RD, SUITE D, MARSHALL, MI 49068-9372
(269) 789-1900
(269) 789-1974
Mailing address
18625 CENTENNIAL RD, SUITE D, MARSHALL, MI 49068-9372
(269) 789-1900
(269) 789-1974
Taxonomy
Speciality
Code
Description
License number
State
207QA0505X
Adult Medicine Physician
Primary
4301033625
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1043379530
NPI INDIVIDUAL
MI
01
—
1101312522
WULFBCINDPIN
MI
01
—
1316145972
GROUP NPI
MI
01
—
1952416877
INDIVIDUAL NPI
MI
05
—
3522410
—
MI
01
—
4301055180
STE LICENSE NUMBER
MI
01
—
700A310290
BLUE CROSS BLUE SHIELD
MI
01
—
CR033625
MICHIGAN LICENSE NUMBER
MI
01
—
F05571
UPIN
MI
01
—
G05602
UPIN
MI
Enumeration date
07/05/2007
Last updated
05/29/2009
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