Basic Information
| Provider Information | |||||||||
| NPI: | 1720154214 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLAREN BAY REGION | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487070068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898943820 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898943820 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | JACKS PORTER | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9898943838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.