Basic Information
| Provider Information | |||||||||
| NPI: | 1700980968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BARAGA COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BCMH PHYSICIAN GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18341 US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | LANSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499468024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9065246118 | ||||||||
| FaxNumber: | 9065245126 | ||||||||
| Practice Location | |||||||||
| Address1: | 18341 US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | LANSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499468024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9065246118 | ||||||||
| FaxNumber: | 9065245126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 08/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | ZWICKEY | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9065243321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0Z71004 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER | 0Z71003 | 01 | MI | BCBS GROUP ID | OTHER |