Basic Information
| Provider Information | |||||||||
| NPI: | 1386624278 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAMILTON COMMUNITY HEALTH NETWORK INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 225 E 5TH ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485021641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104064246 | ||||||||
| FaxNumber: | 8104246029 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E 5TH ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485021641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104064246 | ||||||||
| FaxNumber: | 8104246029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | CLARENCE | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8104064950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HAMILTON COMMUNITY HEALTH NETWORK, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | TYPE 77 | 05 | MI | MEDICAID | 23-1907 | 01 | MI | MEDICARE PART A: 420 W. FIFTH AVE., FLINT, MI 48503 | OTHER | 23-1094 | 05 | MI | MEDICAID | 23-1128 | 05 | MI | MEDICAID | 23-1880 | 01 | MI | MEDICARE PART A: 5710 CLIO RD., FLINT, MI 48504 | OTHER | 23-1886 | 01 | MI | MEDICARE PART A: G-3375 S. SAGINAW ST., BURTON, MI 48529 | OTHER | 23-1806 | 01 | MI | MEDICARE PART A: 4001 N. SAGINAW ST., FLINT, MI 48505 | OTHER |