Basic Information
| Provider Information | |||||||||
| NPI: | 1669548061 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION ST. MARY'S HOSPITAL | ||||||||
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| OtherOrganizationName: | ASCENSION MEDICAL GROUP VASSAR FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487640779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898235020 | ||||||||
| FaxNumber: | 9898237881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 W SAGINAW RD | ||||||||
| Address2: | |||||||||
| City: | VASSAR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487689483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898235020 | ||||||||
| FaxNumber: | 9898237881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCORD | ||||||||
| AuthorizedOfficialFirstName: | LAURILEE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT 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 | 363LF0000X | 4704173083 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 4301079750 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0P11730 | 01 | MI | MEDICARE GROUP DR SARKAR | OTHER | 4771591 | 05 | MI | MEDICAID | 4708328 | 05 | MI | MEDICAID | M10200918 | 01 | MI | DR SARKAR TRICARE | OTHER | 0807911002 | 01 | MI | BCBS | OTHER | 151305 | 01 | MI | DR SARKAR GREATLAKES MCD | OTHER | 01001177 | 01 | MI | HEALTHPLUS | OTHER | 0807911002 | 01 | MI | BCN | OTHER | M10200335 | 01 | MI | JILL MOORE NP TRICARE | OTHER | 150533 | 01 | MI | JILL MOORE NP GREATLAKES | OTHER |