Basic Information
Provider Information | |||||||||
NPI: | 1851409643 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BARAGA COUNTY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BCMH PHYSICIAN GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18341 US HIGHWAY 41 | ||||||||
Address2: |   | ||||||||
City: | LANSE | ||||||||
State: | MI | ||||||||
PostalCode: | 499468024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9065246118 | ||||||||
FaxNumber: | 9065246218 | ||||||||
Practice Location | |||||||||
Address1: | 18341 US HIGHWAY 41 | ||||||||
Address2: |   | ||||||||
City: | LANSE | ||||||||
State: | MI | ||||||||
PostalCode: | 499468024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9065246118 | ||||||||
FaxNumber: | 9065246218 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2006 | ||||||||
LastUpdateDate: | 04/05/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALE | ||||||||
AuthorizedOfficialFirstName: | MARGIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9065243320 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0Z71004 | 01 | MI | BCBS OF MI GROUP | OTHER | 1841555430 | 01 | MI | MEDICAID RHC NUMBER | OTHER | 268646 | 01 | MI | RHC MEDICARE NUMBER | OTHER |