Basic Information
| Provider Information | |||||||||
| NPI: | 1962595454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION STANDISH HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST MARY'S OF MICHIGAN-STANDISH SKILLED | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 W CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | STANDISH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486589526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898464521 | ||||||||
| FaxNumber: | 9898463541 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 W CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | STANDISH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486589526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898464521 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9893629411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 063010 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2000654 | 05 | MI | MEDICAID |