Basic Information
| Provider Information | |||||||||
| NPI: | 1558556332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCLAREN GREATER LANSING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2111 UNIVERISTY PARK DR | ||||||||
| Address2: | STE 800 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179080039 | ||||||||
| FaxNumber: | 5179080038 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W GREENLAWN AVE STE 110 | ||||||||
| Address2: | INGHAM REGIONAL MEDICAL CENTER | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173342121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5179757555 | ||||||||
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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 | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 103T00000X | 064510 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 3375736 | 05 | MI | MEDICAID | 4327359 | 05 | MI | MEDICAID | 4402874 | 05 | MI | MEDICAID | 4363604 | 05 | MI | MEDICAID |