MEDICARE: MEDILODGE OF HILLMAN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	604010	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S9502	OTHER	MI	BLUE CROSS OF MICHIGAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437122801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDILODGE OF HILLMAN LLC

Provider Business Mailing Address
First Line	:	64500 VAN DYKE RD
Second Line	:
City	:	WASHINGTON
State	:	MI
Zip	:	48095-2583
Country	:	US
Telephone Number	:	586-752-5008
Fax Number	:	586-752-7609

Provider Business Practice Location Address
First Line	:	631 CARING ST
Second Line	:
City	:	HILLMAN
State	:	MI
Zip	:	49746-8818
Country	:	US
Telephone Number	:	989-742-4581
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVC OFFICER
Name	:	KATHLEEN DENEAN
Credential	:
Telephone Number	:	586-752-5008

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	05/01/2008

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