Basic Information
| Provider Information | |||||||||
| NPI: | 1891723128 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DICKINSON COUNTY HEALTHCARE SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DICKINSCON CONVENIENT CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 549 | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498010549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067741313 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 S STEPHENSON AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067741313 | ||||||||
| FaxNumber: | 9067765639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9067741313 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 43058200 | 05 | WI | MEDICAID | 16126 | 01 | MI | BCBS FACILITY CODE RHC | OTHER |