| Blue Water Internal Medicine, Pc | |
|
1210 10th Ave Port Huron MI 48060-3406 | |
| (810) 622-3505 | |
| (810) 662-3479 |
| Full Name | Blue Water Internal Medicine, Pc |
|---|---|
| Speciality | Internal Medicine |
| Location | 1210 10th Ave, Port Huron, Michigan |
| Authorized Official Name and Position | Nikki Hack (PRACTICE MANAGER) |
| Authorized Official Contact | 8106623505 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Blue Water Internal Medicine, Pc 1210 10th Ave Port Huron MI 48060-3406 Ph: (810) 662-3505 | Blue Water Internal Medicine, Pc 1210 10th Ave Port Huron MI 48060-3406 Ph: (810) 622-3505 |
| NPI Number | 1255967667 |
|---|---|
| Provider Enumeration Date | 03/17/2020 |
| Last Update Date | 11/18/2024 |
| Medicare PECOS PAC ID | 3577994490 |
|---|---|
| Medicare Enrollment ID | O20200509000126 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1255967667 | NPI | - | NPPES |
| 4301076169 | Other | MI | STATE MEDICAL LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| Provider Name | Emad Daher |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1265415285 PECOS PAC ID: 8022083104 Enrollment ID: I20040901000234 |
| Provider Name | Kaitlyn Marie Mahaffy |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1023879657 PECOS PAC ID: 9436670825 Enrollment ID: I20250228002637 |
| Provider Name | Rachel Renae Distelrath |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1184440158 PECOS PAC ID: 9739600149 Enrollment ID: I20250228003336 |
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