Basic Information
Provider Information | |||||||||
NPI: | 1477716165 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASCENSION ST JOSEPH HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ASCENSION ST JOSEPH HOSPITAL PEDIATRICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 779 | ||||||||
Address2: |   | ||||||||
City: | TAWAS CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 487640779 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9899843770 | ||||||||
FaxNumber: | 9899840038 | ||||||||
Practice Location | |||||||||
Address1: | 110 BEECH ST STE A | ||||||||
Address2: |   | ||||||||
City: | TAWAS CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 487638314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9899843770 | ||||||||
FaxNumber: | 9899840038 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2008 | ||||||||
LastUpdateDate: | 08/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HIGGINS | ||||||||
AuthorizedOfficialFirstName: | CHARITY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIR-MEDICAL PRACTICES | ||||||||
AuthorizedOfficialTelephone: | 9893629304 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.