Basic Information
| Provider Information | |||||||||
| NPI: | 1316968944 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MACKINAC STRAITS HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | MACKINAC STRAITS HOSPITAL AND HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 BURDETTE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066430463 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 BURDETTE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066430463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9066430455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 490030 | MI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 5171127 | 05 | MI | MEDICAID | 1555851 | 05 | MI | MEDICAID |