Basic Information
| Provider Information | |||||||||
| NPI: | 1649555004 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION ST JOSEPH HOSPITAL | ||||||||
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| OtherOrganizationName: | ASCENSION ST JOSEPH HOSPITAL HURON SHORES WALK IN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8936264269 | ||||||||
| FaxNumber: | 9893626527 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 E M 55 | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487638211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893623411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2011 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9893629411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.