Basic Information
| Provider Information | |||||||||
| NPI: | 1558302497 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HURLEY HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 S LINDEN RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485324073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102622160 | ||||||||
| FaxNumber: | 8107322232 | ||||||||
| Practice Location | |||||||||
| Address1: | 4272 W VIENNA RD | ||||||||
| Address2: | |||||||||
| City: | CLIO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484209454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106872850 | ||||||||
| FaxNumber: | 8106879359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BUTERAKOS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8102622160 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363LW0102X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0M32030 | 01 | MI | MEDICARE PTAN | OTHER | 70-0-B5-1070-0 | 01 | MI | BCBS OF MICHIGAN GROUP # | OTHER |