Active NPI
Crystal Lake Clinic, P.C.
- Family Medicine Physician
- Empire, MI
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- Legal business name
- CRYSTAL LAKE CLINIC, P.C.
- Practice address
- 9975 W Ottawa Ave
Empire, MI 49630-9618 - Phone
- (231) 882-9616
- NPI assigned
- Nov 4, 2013
- Last updated
- Nov 4, 2013
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Richard Nielsen, MD
- 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) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | Primary |
Addresses
Primary practice location
9975 W Ottawa Ave
Empire, MI 49630-9618
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 ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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.
National Provider Directory
National Provider DirectoryLocations
9975 W Ottawa Ave
Empire, MI 49630
Phone (231) 213-1115
Practitioners & affiliated clinicians
Practitioners 1
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.
-
- Internal Medicine Physician
- Benzonia, MI
- NPI 1831113273
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1383523200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1383523200000",
"number": "1417386145",
"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": "9975 W OTTAWA AVE",
"city": "EMPIRE",
"state": "MI",
"postal_code": "496309618",
"telephone_number": "231-882-9616"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "CRYSTAL LAKE CLINIC, P.C.",
"organizational_subpart": "NO",
"enumeration_date": "2013-11-04",
"last_updated": "2013-11-04",
"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": "MD"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Empire, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 4, 2013; 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.