Healthcare Provider Details

I. General information

NPI: 1982975397
Provider Name (Legal Business Name): MYMICHIGAN MEDICAL CENTER GLADWIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 SOUTH ROSS STREET
BEAVERTON MI
48612
US

IV. Provider business mailing address

4000 WELLNESS DR
MIDLAND MI
48670-2000
US

V. Phone/Fax

Practice location:
  • Phone: 989-246-3500
  • Fax: 989-246-3519
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RAYMOND H STOVER
Title or Position: PRESIDENT AND CEA
Credential:
Phone: 989-246-6201