NPIMap

Organization Active NPI

Crystal Lake Clinic P.C.

  • Family Medicine Physician
  • Elk Rapids, MI
National Provider Identifier
1053780072
Registry record updated Sep 21, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CRYSTAL LAKE CLINIC P.C.
Practice address
124 Ames St
Elk Rapids, MI 49629-9449
Phone
(231) 264-8282
Fax
(231) 264-6655
NPI assigned
Sep 21, 2015
Last updated
Sep 21, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 21, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Richard C Nielsen, M.D.NPI 1831113273
Title
President
Phone
(231) 882-9661

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

124 Ames St
Elk Rapids, MI 49629-9449

Mailing address

6227 Frankfort Hwy
Benzonia, MI 49616-8632
Phone (231) 882-9661

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040802000634 MI Part B Supplier - Clinic/Group Practice 0648259010 Receives reassigned benefits from 39 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Traverse City, MI; Suttons Bay, MI; Manton, MI; Manistee, MI; Interlochen, MI; Frankfort, MI; Elk Rapids, MI; Bear Lake, MI…

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2103176Crystal Lake Clinic, PC124 Ames Street, Elk Rapids, MI 49629Certificate of waiverOct 6, 2027

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1442793600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1442793600000",
    "number": "1053780072",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6227 FRANKFORT HWY",
            "city": "BENZONIA",
            "state": "MI",
            "postal_code": "496168632",
            "telephone_number": "231-882-9661",
            "fax_number": "231-882-9616"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "124 AMES ST",
            "city": "ELK RAPIDS",
            "state": "MI",
            "postal_code": "496299449",
            "telephone_number": "231-264-8282",
            "fax_number": "231-264-6655"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRYSTAL LAKE CLINIC P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-09-21",
        "last_updated": "2015-09-21",
        "status": "A",
        "authorized_official_last_name": "NIELSEN",
        "authorized_official_first_name": "RICHARD",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "231-882-9661",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Elk Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.