Basic Information
| Provider Information | |||||||||
| NPI: | 1881973253 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCLAREN BAY REGION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5170 RIFLE RIVER TRL | ||||||||
| Address2: | |||||||||
| City: | ALGER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486109343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898735323 | ||||||||
| FaxNumber: | 9898733673 | ||||||||
| Practice Location | |||||||||
| Address1: | 5170 RIFLE RIVER TRL | ||||||||
| Address2: | |||||||||
| City: | ALGER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898735323 | ||||||||
| FaxNumber: | 9898733673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2011 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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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 | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.