Basic Information
| Provider Information | |||||||||
| NPI: | 1437233426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION ST JOSEPH HOSPITAL | ||||||||
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| OtherOrganizationName: | ASCENSION ST JOSEPH HOSPITAL FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897391441 | ||||||||
| FaxNumber: | 9893629925 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HEMLOCK | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893629411 | ||||||||
| FaxNumber: | 9893629925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9893629411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080C56012 | 01 | MI | BCBS-FAMILY PRACTICE | OTHER |