Basic Information
| Provider Information | |||||||||
| NPI: | 1659868206 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MACKINAC STRAITS HEALTH SYSTEM INC | ||||||||
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| OtherOrganizationName: | ST. IGNACE MEDICAL CLINIC, ANNEX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811048 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1140 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066430400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2018 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPRAGUE | ||||||||
| AuthorizedOfficialFirstName: | SONJA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING AND ENROLLMENTS | ||||||||
| AuthorizedOfficialTelephone: | 9066430451 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MACKINAC STRAITS HEALTH SYSTEM INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 238716 | 01 | MEDICARE | OTHER |