Basic Information
| Provider Information | |||||||||
| NPI: | 1447298849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDMICHIGAN GLADWIN PINES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 449 QUARTER ST | ||||||||
| Address2: | |||||||||
| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486241918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894263430 | ||||||||
| FaxNumber: | 9892466331 | ||||||||
| Practice Location | |||||||||
| Address1: | 449 QUARTER ST | ||||||||
| Address2: | |||||||||
| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486241918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894263430 | ||||||||
| FaxNumber: | 9892466331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WRZESINSKI | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PATIENT ACCOUNTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9896331486 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDMICHIGAN HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 264028 | MI | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 1070000264 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1996373 | 05 | MI | MEDICAID | 09904 | 01 | MI | BCBSM | OTHER |