SOUTHERN GRAND TRAVERSE MEDICAL (NPI# 1851580815) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1851580815 |
| Entity Type | Organization |
| Organization Name | SOUTHERN GRAND TRAVERSE MEDICAL |
| Practice Address |
401 Munson Ave Traverse City MI 49686-3041 |
| Practice Telephone | 2319954902 |
| Practice Fax Number | 2319327816 |
| Mailing Telephone | 2319954902 |
| Mailing Fax Number | 2319327816 |
| Enumeration Date | 2007-10-16 |
| Last Update Date | 2007-10-16 |
| Authorized Official Name | GARY J SCHAUB (OWNER) |
| Authorized Official Telephone | 2319954902 |
| Authorized Official Credential | PA-C |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 363AM0700X |
Physician Assistant Specialization: Medical |
5601001376 | MI | Physician Assistants & Advanced Practice Nursing Providers |
| Street Address |
401 MUNSON AVE |
| City | TRAVERSE CITY |
| State | MI |
| Zip Code | 49686-3041 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1629076294 | Michael J Parker | Emergency Medicine | 401 Munson Ave, Traverse City, MI 49686 | 2005-07-08 |
| 1134422777 | Bayside Doc's Urgent Care Office | General Practice | 401 Munson Ave, Traverse City, MI 49686-3041 | 2010-12-20 |
| 1740324664 | Carol Ann Straight | Nurse Practitioner | 401 Munson Ave, Traverse City, MI 49686-3041 | 2007-02-16 |
| 1316092943 | Bayside Docs Urgent Care Plc | Clinic/Center | 401 Munson Ave, Traverse City, MI 49686-3041 | 2007-01-24 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1245877208 | Jessica Marie Glowacki | Behavior Technician | 935 Hemlock St, Traverse City, MI 49686 | 2019-12-09 |
| 1568011542 | Joanne Kressley | Technician | 1693 Maylane Apt. 104, Traverse City, MI 49686 | 2019-09-11 |
| 1194283846 | Pace North | PACE Provider Organization | 2325 Garfield Road N., Traverse City, MI 49686 | 2019-03-12 |
| 1245749225 | Margaret Anne Goss | Speech-Language Pathologist | 1105 E. Eighth Street, Traverse City, MI 49686 | 2017-09-22 |
| 1467981811 | Joan Joyce Shirilla | Social Worker | 2124 Twin Eagles Dr, Traverse City, MI 49686 | 2017-06-08 |
| 1770028763 | Rehab and Mobility Systems, LLC | Durable Medical Equipment & Medical Supplies | 707 Parsons, Traverse City, MI 49686 | 2016-12-29 |
| 1629511316 | Kaitlyn Grangood | Social Worker | 415 Munson Avenue, Ste 101, Traverse City, MI 49686 | 2016-11-29 |
| 1811441132 | Jeffrey D Goodwin | Counselor | 430 Fair St., Traverse City, MI 49686 | 2016-08-04 |
| 1053779918 | Thomas Osborne | Counselor | 2014 Phelps Rd., Traverse City, MI 49686 | 2016-02-08 |
| 1982079588 | Marsha Lynne Dallas | Counselor | 2240 South Airport Road, Traverse City, MI 49686 | 2015-12-08 |
| Find all providers in zip 49686 | ||||
| Taxonomy Code | 363AM0700X |
| Grouping | Physician Assistants & Advanced Practice Nursing Providers |
| Classification | Physician Assistant |
| Specialization | Medical |
| Definition to come... |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1992810360 | Laura Leigh Worthington | Physician Assistant | 13491 S Bugai Rd, Traverse City, MI 49684-8421 | 2006-08-19 |
| 1598752768 | Perry Ray Tiernan | Physician Assistant | 3074 Us 31 S, Traverse City, MI 49684-4533 | 2005-10-04 |
| 1114928637 | Mary Kathryn Douglas | Physician Assistant | 5015 N Royal Dr, Traverse City, MI 49684-9292 | 2005-08-09 |
| 1043857196 | Derek Hendrickson | Physician Assistant | 1200 Sixth St Ste 200, Traverse City, MI 49684-2369 | 2019-12-09 |
| 1649735226 | Morgan Kelsey Olson | Physician Assistant | 1105 Sixth St, Traverse City, MI 49684-2345 | 2019-02-07 |
| 1851833198 | Katharine Ella Venner | Physician Assistant | 1105 6th St, Traverse City, MI 49684-2349 | 2016-11-16 |
| 1427417708 | Christine E Miliken | Physician Assistant | 3074 N Us 31 S, Traverse City, MI 49684-4533 | 2016-02-16 |
| 1144503491 | Jesse Kogelman | Physician Assistant | 550 Munson Ave, Suite 200, Traverse City, MI 49686-3580 | 2011-09-22 |
| 1952691768 | Alisha Marie Cole | Physician Assistant | 4045 W Royal Dr, Traverse City, MI 49684-8965 | 2011-04-13 |
| 1467606350 | Carrie M Sorensen | Physician Assistant | 1200 Sixth St Ste 200, Traverse City, MI 49684-2369 | 2008-11-05 |
| Find all providers in TRAVERSE CITY | ||||
| City | TRAVERSE CITY |
| Zip Code | 49686 |
Please comment or provide details below to improve the information on SOUTHERN GRAND TRAVERSE MEDICAL.
| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.