Basic Information
Provider Information | |||||||||
NPI: | 1821610965 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCLAREN CENTRAL MICHIGAN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1221 SOUTH DR | ||||||||
Address2: |   | ||||||||
City: | MT PLEASANT | ||||||||
State: | MI | ||||||||
PostalCode: | 488583257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897726700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4489 M 61 | ||||||||
Address2: | STES 1, 2 | ||||||||
City: | STANDISH | ||||||||
State: | MI | ||||||||
PostalCode: | 486589273 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9898462600 | ||||||||
FaxNumber: | 9898462601 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2020 | ||||||||
LastUpdateDate: | 03/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SOULES | ||||||||
AuthorizedOfficialFirstName: | TARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
AuthorizedOfficialTelephone: | 9897726818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.