Pine Trees Medical Office PC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

4301028315 Issued in MI

Legal business name

PINE TREES MEDICAL OFFICE PC

Practice address

11610 Waldron Rd
Jerome, MI 49249-9637

Phone

(517) 688-4842

Fax

(517) 688-4842

NPI assigned

Sep 7, 2005

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Roy W Boyer, MD

Title

President

Phone

(517) 688-4842

Specialties & licenses 1

Addresses

Other identifiers 3

Other names 1

• Mark A Kallus MD PC Former legal business name

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

{
    "created_epoch": "1126051200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1487648374",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11610 WALDRON RD",
            "city": "JEROME",
            "state": "MI",
            "postal_code": "492499637",
            "telephone_number": "517-688-4842",
            "fax_number": "517-688-4842"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11610 WALDRON RD",
            "city": "JEROME",
            "state": "MI",
            "postal_code": "492499637",
            "telephone_number": "517-688-4842",
            "fax_number": "517-688-4842"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINE TREES MEDICAL OFFICE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-07",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BOYER",
        "authorized_official_first_name": "ROY",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "517-688-4842",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MI",
            "license": "4301028315",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CARE NETWORK HMO",
            "identifier": "P41335",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "1 106914130",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4462854",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mark A Kallus MD PC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Alhambra St. Francis Camp on the Lake (St. Francis Camp)
• Adrienne Elizabeth Delong
• Charles I Hicks, R.PH.
• Phoenix Rising Therapeutic Services
• Crystal Lynn Schell, LPN

• Internal Medicine Physician in Jerome, MI
• Providers in Jerome, 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 Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.