Healthcare Provider Details

I. General information

NPI: 1083772826
Provider Name (Legal Business Name): HURON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S VAN DYKE RD
BAD AXE MI
48413-9615
US

IV. Provider business mailing address

1100 S VAN DYKE RD
BAD AXE MI
48413-9615
US

V. Phone/Fax

Practice location:
  • Phone: 989-269-9521
  • Fax: 989-269-5260
Mailing address:
  • Phone: 989-269-9521
  • Fax: 989-269-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRL040876
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberRD002414
License Number StateMI

VIII. Authorized Official

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