NPIMap

Individual provider Active NPI

Daniel C Souphis, D.O.

  • Family Medicine Physician
  • Fort Gratiot, MI
National Provider Identifier
1225004252
Registry record updated Sep 4, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
5101011575 Issued in MI
Practice address
4190 24TH Ave
Fort Gratiot, MI 48059-3882
Phone
(810) 989-7788
Fax
(810) 989-7799
NPI assigned
Feb 28, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 4, 2014

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 5101011575 MI Primary

Addresses

Primary practice location

4190 24TH Ave
Fort Gratiot, MI 48059-3882

Mailing address

4190 24TH Ave
Fort Gratiot, MI 48059-3882
Phone (810) 989-7788

Other identifiers 1

IdentifierTypeStateIssuer
1225004252MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100108000872 MI Practitioner - Family Practice 3173664406 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
At Still University of Health Sciences, College of Osteo Med, Kirksville, 1991
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Physician Healthcare Network PCGroup PAC ID 3476456252, 30 clinicians

Practice addresses (Care Compare)

3350 Gratiot Blvd
Marysville, MI 48040-2121
Phone (810) 364-4000

4190 24TH Ave
Fort Gratiot, MI 48059-3882
Phone (810) 989-7788

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Removal or shaving of skin growth1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Osteopathy, Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
5101011575MIMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Physician Healthcare Network, PC Family Medicine CurrentSince Apr 1, 1996 Accepting new patients
Port Huron Opco LLC Past Accepting new patients
Marwood Manor Nursing Home Past Accepting new patients

Locations

4190 24th Ave
Fort Gratiot, MI 48059
Phone (810) 216-4300

3350 Gratiot Blvd
Marysville, MI 48040
Phone (810) 364-4000

Interoperability endpoints

  • Direct secure messaging: daniel.souphis.1@11357.direct.athenahealth.com

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 11

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1141084800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1409788800000",
    "number": "1225004252",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4190 24TH AVE",
            "city": "FORT GRATIOT",
            "state": "MI",
            "postal_code": "480593882",
            "telephone_number": "810-989-7788",
            "fax_number": "810-989-7799"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4190 24TH AVE",
            "city": "FORT GRATIOT",
            "state": "MI",
            "postal_code": "480593882",
            "telephone_number": "810-989-7788",
            "fax_number": "810-989-7799"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SOUPHIS",
        "first_name": "DANIEL",
        "middle_name": "C",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-02-28",
        "last_updated": "2014-09-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "MI",
            "license": "5101011575",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1225004252",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Gratiot, MI

Sources for this page

Verify at the official NPI Registry.