Basic Information
| Provider Information | |||||||||
| NPI: | 1164795357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HURLEY HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HURLEY HEALTH SERVICES URGENT CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 S LINDEN RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485324073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102622160 | ||||||||
| FaxNumber: | 8107322232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1794 N LAPEER RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | LAPEER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484467664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102451800 | ||||||||
| FaxNumber: | 8109694407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2012 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | BUTERAKOS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8102622160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0M32030 | 01 | MI | MEDICARE PTAN | OTHER | OB50731 | 01 | MI | BCBSM URGENT CARE GROUP PIN | OTHER | OD40125 | 01 | MI | BCBSM | OTHER | 70-0-B5-1070-0 | 01 | MI | BLUE CROSS BLUE SHIELD GROUP # | OTHER | OM32030 | 01 | MI | MEDICARE GROUP # | OTHER |