Basic Information
| Provider Information | |||||||||
| NPI: | 1508993361 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MYMICHIGAN MEDICAL CENTER GLADWIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 WELLNESS DR | ||||||||
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| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486702000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 515 QUARTER STREET | ||||||||
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| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486241959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894269286 | ||||||||
| FaxNumber: | 9898391304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | STOVER | ||||||||
| AuthorizedOfficialFirstName: | RAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9892466203 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 430B610020 | 01 | MI | BL SHIELD CRNA GROUP | OTHER |