Blue Water Internal Medicine, PC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

Legal business name

BLUE WATER INTERNAL MEDICINE, PC

Practice address

1210 10TH Ave
Port Huron, MI 48060-3406

Phone

(810) 622-3505

Fax

(810) 662-3479

NPI assigned

Mar 17, 2020

Organization subpart

No

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

Authorized official

Name

Nikki Hack

Title

Practice Manager

Phone

(810) 662-3505

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in MI

Enrollment records 1

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

CLIA laboratory certificates

Interoperability endpoints

• FHIR API: https://fhir4.healow.com/fhir/r4/BIGACD

Practitioners 4

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.

• Emad Daher, MD

  • Internal Medicine Physician
  • Port Huron, MI
  • NPI 1265415285
  Medicare reassignment Care Compare group NPD
• Rachel Distelrath, FNP-BC

  • Family Nurse Practitioner
  • Port Huron, MI
  • NPI 1184440158
  Medicare reassignment Care Compare group NPD
• Kaitlyn Marie Mahaffy

  • Family Nurse Practitioner
  • Port Huron, MI
  • NPI 1023879657
  Medicare reassignment Care Compare group NPD
• Casey Renno, AGNP-C

  • Gerontology Nurse Practitioner
  • Port Huron, MI
  • NPI 1144866013
  Medicare reassignment Care Compare group NPD

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

{
    "created_epoch": "1584403200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1731888000000",
    "number": "1255967667",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1210 10TH AVE",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603406",
            "telephone_number": "810-662-3505",
            "fax_number": "810-662-3479"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1210 10TH AVE",
            "city": "PORT HURON",
            "state": "MI",
            "postal_code": "480603406",
            "telephone_number": "810-622-3505",
            "fax_number": "810-662-3479"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE WATER INTERNAL MEDICINE, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-03-17",
        "last_updated": "2024-11-18",
        "certification_date": "2024-11-18",
        "status": "A",
        "authorized_official_last_name": "HACK",
        "authorized_official_first_name": "NIKKI",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "810-662-3505"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE MEDICAL LICENSE",
            "identifier": "4301076169",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Blue Water ASC LLC (Blue Water Surgery Center, LLC)
• Blue Water Center for Christian Counseling P.C.
• Blue Water Center for Independent Living
• Blue Water Dental Group Port Huron P.C.
• Blue Water Eye Care Associates PC
• Blue Water Medical Massage PLLC
• Blue Water Medical PLLC
• Blue Water OB & GYN PC
• Blue Water Oncology PC
• Blue Water Pharmacy LLC (Blue Water Pharmacy)

• Internal Medicine Physician in Port Huron, MI
• Providers in Port Huron, MI by specialty
• Internal Medicine Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2024; 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.