Basic Information
Provider Information | |||||||||
NPI: | 1659465094 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASCENSION STANDISH HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 779 | ||||||||
Address2: |   | ||||||||
City: | TAWAS CITY | ||||||||
State: | MI | ||||||||
PostalCode: | 487640779 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9898464521 | ||||||||
FaxNumber: | 9898463541 | ||||||||
Practice Location | |||||||||
Address1: | 805 W CEDAR ST | ||||||||
Address2: |   | ||||||||
City: | STANDISH | ||||||||
State: | MI | ||||||||
PostalCode: | 486589526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9898464521 | ||||||||
FaxNumber: | 9898463541 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2006 | ||||||||
LastUpdateDate: | 07/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCORD | ||||||||
AuthorizedOfficialFirstName: | LAURILEE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
AuthorizedOfficialTelephone: | 9893629411 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 060020 | MI | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 5172080 | 05 | MI |   | MEDICAID | 1556090 | 05 | MI |   | MEDICAID |