Healthcare Provider Details

I. General information

NPI: 1417411760
Provider Name (Legal Business Name): DICKINSON COUNTY HEALTHCARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 S STEPHENSON AVE STE 205
IRON MOUNTAIN MI
49801-3649
US

IV. Provider business mailing address

PO BOX 549
IRON MOUNTAIN MI
49801-0549
US

V. Phone/Fax

Practice location:
  • Phone: 906-774-1313
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ALICIA R HENDERSON
Title or Position: PHYSICIAN BILLING SUPERVISOR
Credential:
Phone: 906-774-1313