1962595983 NPI number — MCLAREN HEALTH MANAGEMENT GROUP

Table of content: (NPI 1962595983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962595983 NPI number — MCLAREN HEALTH MANAGEMENT GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCLAREN HEALTH MANAGEMENT GROUP
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:
1962595983
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 CAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVISON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48423-9016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-496-8640
Provider Business Mailing Address Fax Number:
231-627-1652

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
761 LAFAYETTE AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEBOYGAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-627-7157
Provider Business Practice Location Address Fax Number:
231-627-1652
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOY
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
CFO/VICE PRESIDENT
Authorized Official Telephone Number:
810-496-8633

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  163520 , 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: 08708 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2698527 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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