1891980306 NPI number — KALKASKA MEMORIAL HEALTH CENTER

Table of content: (NPI 1891980306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891980306 NPI number — KALKASKA MEMORIAL HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KALKASKA MEMORIAL HEALTH CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891980306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4062 W ROYAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49684-8965
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-935-5652
Provider Business Mailing Address Fax Number:
231-935-7792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 2ND ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALKASKA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-258-3680
Provider Business Practice Location Address Fax Number:
231-258-3695
Provider Enumeration Date:
09/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAYMOND
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
231-258-3651

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: D8982 . This is a "BCBSM PRIMARY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1891980306 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09417 . This is a "BCBSM -SUPPLEMENTAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".