Basic Information
Provider Information | |||||||||
NPI: | 1568414589 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MIDMICHIGAN MEDICAL CENTER CLARE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 703 N MCEWAN ST | ||||||||
Address2: |   | ||||||||
City: | CLARE | ||||||||
State: | MI | ||||||||
PostalCode: | 486171440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9898025000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 703 N MCEWAN ST | ||||||||
Address2: |   | ||||||||
City: | CLARE | ||||||||
State: | MI | ||||||||
PostalCode: | 486171440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9898025000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 07/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STOVER | ||||||||
AuthorizedOfficialFirstName: | RAYMOND | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 9898025103 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 180010 | MI | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 5170344 | 05 | MI |   | MEDICAID | 00138 | 01 | MI | BCBSM | OTHER | 1557640 | 05 | MI |   | MEDICAID |