Basic Information
| Provider Information | |||||||||
| NPI: | 1801860218 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCLAREN BAY REGION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487086831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898943000 | ||||||||
| FaxNumber: | 9898918172 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 E MIDLAND RD | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487062835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898943000 | ||||||||
| FaxNumber: | 9898918172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACKS PORTER | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9898943838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 1801860218 | 05 | MI | MEDICAID | 23T041 | 01 | MI | MEDICARE PROVIDER NUMBER | OTHER | 2778539 | 01 | MI | MEDICAID PROVIDER NUMBER | OTHER |