Basic Information
| Provider Information | |||||||||
| NPI: | 1336462001 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY MENTAL HEALTH FOR CENTRAL MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 S CRAPO ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488582941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897736961 | ||||||||
| FaxNumber: | 9899534451 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S CRAPO ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488582941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897736961 | ||||||||
| FaxNumber: | 9899534451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2010 | ||||||||
| LastUpdateDate: | 11/30/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/23/2018 | ||||||||
| NPIReactivationDate: | 11/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | OBERMESIK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9897725930 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 364SP0808X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 2084P0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 4344340 | 05 | MI | MEDICAID | 4352754 | 05 | MI | MEDICAID |