Basic Information
Provider Information | |||||||||
NPI: | 1144878745 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASCENSION ST. MARY'S HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASCENSION MEDICAL GROUP PALLIATIVE CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 779 | ||||||||
Address2: |   | ||||||||
City: | TAWAS CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 487640779 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9894973226 | ||||||||
FaxNumber: | 9894973146 | ||||||||
Practice Location | |||||||||
Address1: | 4599 TOWNE CENTRE RD | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486042804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9894973226 | ||||||||
FaxNumber: | 9894973146 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2019 | ||||||||
LastUpdateDate: | 08/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCORD | ||||||||
AuthorizedOfficialFirstName: | LAURIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ENROLLMENT COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 9893629411 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0002X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
No ID Information.