Basic Information
| Provider Information | |||||||||
| NPI: | 1295040798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACKINAC STRAITS HEALTH SYSTEM INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOSES DIALYSIS UNIT | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066437821 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066437821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2010 | ||||||||
| LastUpdateDate: | 08/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9066430435 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.