Basic Information
| Provider Information | |||||||||
| NPI: | 1134281132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND TRAVERSE BAND FAMILY HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 N STALLMAN RD | ||||||||
| Address2: | |||||||||
| City: | SUTTONS BAY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496829158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315347200 | ||||||||
| FaxNumber: | 2315347460 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 N STALLMAN RD | ||||||||
| Address2: | |||||||||
| City: | SUTTONS BAY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496829158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315347200 | ||||||||
| FaxNumber: | 2315347460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 03/15/2019 | ||||||||
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| AuthorizedOfficialLastName: | CHAMBERS | ||||||||
| AuthorizedOfficialFirstName: | LOI | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2315347477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1376553586 | 05 | MI | MEDICAID | 700D545020 | 01 | MI | BCBS | OTHER |