Basic Information
| Provider Information | |||||||||
| NPI: | 1154367431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MYMICHIGAN MEDICAL CENTER ALMA | ||||||||
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| OtherOrganizationName: | GREAT LAKES RENAL NETWORK, ALMA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 WELLNESS DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486700001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 E WARWICK DR | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488011014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894663330 | ||||||||
| FaxNumber: | 9894632540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | PEIRCE | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER PATIENT ACCOUNTS | ||||||||
| AuthorizedOfficialTelephone: | 9893567597 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 00233 | 01 | MI | BCBSM | OTHER | 405170738 | 05 | MI | MEDICAID |