Provider Demographics
NPI:1447460852
Name:RUSSELL VAN HOUZEN, MD, PLC
Entity type:Organization
Organization Name:RUSSELL VAN HOUZEN, MD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:NEIL
Authorized Official - Last Name:VAN HOUZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-0888
Mailing Address - Street 1:10161 E PICKWICK CT
Mailing Address - Street 2:SUITE E
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5239
Mailing Address - Country:US
Mailing Address - Phone:231-935-0888
Mailing Address - Fax:231-935-0890
Practice Address - Street 1:10161 E PICKWICK CT
Practice Address - Street 2:SUITE E
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5239
Practice Address - Country:US
Practice Address - Phone:231-935-0888
Practice Address - Fax:231-935-0890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1096875Medicaid
MIB45852Medicare UPIN
MI0281021Medicare ID - Type Unspecified