Organization
NORTHRIDGE FAMILY PRACTICE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEBRA PROVOAST NP (OWNER)
(989) 728-6000
Entity
Organization
Contact information
Practice address
3190 NORTHRIDGE DRIVE, HALE, MI 48739-9276
(989) 728-6000
(989) 728-6003
Mailing address
PO BOX 279, HALE, MI 48739-0279
(198) 972-8600
(989) 728-6003
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
4301061417
MI
207RC0001X
Clinical Cardiac Electrophysiology Physician
Primary
5101011670
MI
Other
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
Enumeration date
04/25/2007
Last updated
01/13/2009
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