Healthcare Provider Details

I. General information

NPI: 1053690438
Provider Name (Legal Business Name): MCLAREN BAY REGION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 LOCKWOOD LN
MIO MI
48647
US

IV. Provider business mailing address

558 LOCKWOOD LN PO BOX 460
MIO MI
48647-9387
US

V. Phone/Fax

Practice location:
  • Phone: 989-826-3271
  • Fax: 989-826-6749
Mailing address:
  • Phone: 989-826-3271
  • Fax: 989-826-6749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE C JACKS PORTER
Title or Position: CFO
Credential:
Phone: 989-894-3838