Healthcare Provider Details

I. General information

NPI: 1629107552
Provider Name (Legal Business Name): THUNDER BAY COMMUNITY HEALTH SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15774 STATE STREET
HILLMAN MI
49746
US

IV. Provider business mailing address

PO BOX 427
HILLMAN MI
49746-0427
US

V. Phone/Fax

Practice location:
  • Phone: 989-742-4583
  • Fax: 989-742-4298
Mailing address:
  • Phone: 989-742-4583
  • Fax: 989-742-4298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: RICHARD BATES
Title or Position: INTERIM CEO
Credential:
Phone: 989-742-4583