NPIMap

Organization Active NPI

Well-Spring Psychiatry, P.C.

  • Psychiatry Physician
  • Traverse City, MI
National Provider Identifier
1922112077
Registry record updated Apr 18, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
WELL-SPRING PSYCHIATRY, P.C.
Practice address
1421 Wayne St
Traverse City, MI 49684-1432
Phone
(231) 922-9625
Fax
(231) 929-5594
NPI assigned
Aug 18, 2006
Last updated
Apr 18, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 18, 2008

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

Authorized official

Name
Marilyn Eileen Conlon, M.D.,NPI 1548373186
Title
President
Phone
(231) 922-9625

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X NU Primary

Addresses

Primary practice location

1421 Wayne St
Traverse City, MI 49684-1432

Mailing address

PO Box 107
Lake Ann, MI 49650-0107
Phone (231) 922-9625

Other identifiers 2

IdentifierTypeStateIssuer
P00075183OtherMIRR MEDICARE
4275243MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040216000660 MI Part B Supplier - Clinic/Group Practice 4486549961 Receives reassigned benefits from 2 practitioners
Practice locations: Traverse City, MI

National Provider Directory

National Provider Directory

Locations

12935 S West Bay Shore Dr
Ste 330
Traverse City, MI 49684
Phone (231) 933-4661

13310 S West Bay Shore Dr
Ste A
Traverse City, MI 49684
Phone (231) 922-9625

Practitioners & affiliated clinicians

Practitioners 10

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.

NPI Registry JSON

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

{
    "created_epoch": "1155859200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1208476800000",
    "number": "1922112077",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 107",
            "city": "LAKE ANN",
            "state": "MI",
            "postal_code": "496500107",
            "telephone_number": "231-922-9625",
            "fax_number": "231-929-5594"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1421 WAYNE ST",
            "city": "TRAVERSE CITY",
            "state": "MI",
            "postal_code": "496841432",
            "telephone_number": "231-922-9625",
            "fax_number": "231-929-5594"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WELL-SPRING PSYCHIATRY, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-18",
        "last_updated": "2008-04-18",
        "status": "A",
        "authorized_official_last_name": "CONLON",
        "authorized_official_first_name": "MARILYN",
        "authorized_official_middle_name": "EILEEN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "231-922-9625",
        "authorized_official_credential": "M.D.,"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RR MEDICARE",
            "identifier": "P00075183",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4275243",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Traverse City, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 18, 2008; 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.