Healthcare Provider Details

I. General information

NPI: 1396176830
Provider Name (Legal Business Name): HURON MEDICAL CNETER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 S VAN DYKE RD
BAD AXE MI
48413-9635
US

IV. Provider business mailing address

1080 S VAN DYKE RD
BAD AXE MI
48413-9635
US

V. Phone/Fax

Practice location:
  • Phone: 989-269-7775
  • Fax: 989-269-7677
Mailing address:
  • Phone: 989-269-7775
  • Fax: 989-269-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101015749
License Number StateMI

VIII. Authorized Official

Name: MICHAEL ERIC JOHNSTON
Title or Position: PRESIDENT & CEO
Credential:
Phone: 989-803-7127