Healthcare Provider Details

I. General information

NPI: 1790746964
Provider Name (Legal Business Name): THUNDER BAY CLINIC MANAGEMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 US 23 NORTH
ALPENA MI
49707
US

IV. Provider business mailing address

1065 US 23 NORTH
ALPENA MI
49707
US

V. Phone/Fax

Practice location:
  • Phone: 989-354-0607
  • Fax: 989-356-6710
Mailing address:
  • Phone: 989-354-0607
  • Fax: 989-356-6710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberBB012930
License Number StateMI

VIII. Authorized Official

Name: MRS. JANE E HARDIES
Title or Position: OFFICE MANAGER
Credential:
Phone: 989-354-0607