MEDICARE: BANGOR HEALTH CENTER

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	251S00000X	Community/Behavioral Health Agency
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50-0-H01075-0	OTHER	MI	BLUE CROSS BLUE SHIELD OF MICHIGAN

General Provider Information

NPI Number	:	1841436128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANGOR HEALTH CENTER

Provider Business Mailing Address
First Line	:	PO BOX 249
Second Line	:	801 HAZEN STREET, SUITE C.
City	:	PAW PAW
State	:	MI
Zip	:	49079-0249
Country	:	US
Telephone Number	:	269-657-5574
Fax Number	:	269-657-3474

Provider Business Practice Location Address
First Line	:	803 WEST ARLINGTON STREET
Second Line	:
City	:	BANGOR
State	:	MI
Zip	:	49013-1108
Country	:	US
Telephone Number	:	269-427-6810
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. DEBRA L.R. HESS
Credential	:
Telephone Number	:	269-567-5574

Provider Enumeration Date	:	12/17/2008
Last Update Date	:	05/07/2009

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Directions to “BANGOR HEALTH CENTER ” Practice Location

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