Basic Information
| Provider Information | |||||||||
| NPI: | 1003996679 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ASCENSION ST JOSEPH HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IMC/ONC PART B | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893626108 | ||||||||
| FaxNumber: | 9893620161 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEMLOCK | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893629411 | ||||||||
| FaxNumber: | 9893629925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HIGGINS | ||||||||
| AuthorizedOfficialFirstName: | CHARITY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIR-MEDICAL PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 9893629304 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110C56009 | 01 | MI | BCBS -INTERNAL MED/PEDS | OTHER |