Basic Information
| Provider Information | |||||||||
| NPI: | 1629120415 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNISING MEMORIAL HOSPITAL ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAY CARE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 SAND POINT ROAD | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874338 | ||||||||
| FaxNumber: | 9063872825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 SAND POINT ROAD | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874338 | ||||||||
| FaxNumber: | 9063872825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/02/2017 | ||||||||
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| AuthorizedOfficialLastName: | RAUTIO | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9063874110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNISING MEMORIAL HOSPITAL ASSOCIATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 1060000115 | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0Z21000 | 01 | MI | BLUE SHIELD | OTHER | 23-8650 | 01 | MI | RHC CERTIFICATION NUMBER (CMS) | OTHER |