Basic Information
| Provider Information | |||||||||
| NPI: | 1184751851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MYMICHIGAN MEDICAL CENTER MIDLAND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 WELLNESS DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486700001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898393000 | ||||||||
| FaxNumber: | 9898391304 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 WELLNESS DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486700001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898393000 | ||||||||
| FaxNumber: | 9898391304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | BRYAN | ||||||||
| AuthorizedOfficialMiddleName: | REX | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT AND COO | ||||||||
| AuthorizedOfficialTelephone: | 9898391322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 480E660260 | 01 | MI | BL SHIELD PODIATRY GROUP | OTHER |