Basic Information
| Provider Information | |||||||||
| NPI: | 1659536035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MACKINAC STRAITS HEALTH SYSTEM INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MACKINAC STRAITS HOSPITAL AND HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066430373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066438585 | ||||||||
| FaxNumber: | 9066430373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2008 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | SPRAGUE | ||||||||
| AuthorizedOfficialFirstName: | SONJA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9066430451 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 700D90255 | 01 | MI | BLUE SHIELD | OTHER |