Basic Information
| Provider Information | |||||||||
| NPI: | 1164410841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION ST JOSEPH HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASCENSION ST JOSEPH HOSPITAL INTERNAL MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 295 MAPLE ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487639352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893626108 | ||||||||
| FaxNumber: | 9893620161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9893629411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.