NPIMap

Organization Active NPI

Crystal Lake Clinic PC

  • Family Medicine Physician
  • Manistee, MI
National Provider Identifier
1134491731
Registry record updated Jan 30, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CRYSTAL LAKE CLINIC PC
Practice address
1806 E Parkdale Ave Ste 2
Manistee, MI 49660-9364
Phone
(231) 882-9661
NPI assigned
Jan 30, 2012
Last updated
Jan 30, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 30, 2012

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

Authorized official

Name
Richard 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

1806 E Parkdale Ave Ste 2
Manistee, MI 49660-9364

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
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

National Provider Directory

National Provider Directory

Locations

1975 Stirling Dr
Interlochen, MI 49643
Phone (231) 275-0166

2283 E M 113
Kingsley, MI 49649
Phone (231) 263-0700

Practitioners & affiliated clinicians

Practitioners 42

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.

View all 42

NPI Registry JSON

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

{
    "created_epoch": "1327881600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1327881600000",
    "number": "1134491731",
    "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": "1806 E PARKDALE AVE STE 2",
            "city": "MANISTEE",
            "state": "MI",
            "postal_code": "496609364",
            "telephone_number": "231-882-9661"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRYSTAL LAKE CLINIC PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-01-30",
        "last_updated": "2012-01-30",
        "status": "A",
        "authorized_official_last_name": "NIELSEN",
        "authorized_official_first_name": "RICHARD",
        "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 Manistee, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.