Healthcare Provider Details

I. General information

NPI: 1942370754
Provider Name (Legal Business Name): MCLAREN NORTHERN MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 CONNABLE AVE
PETOSKEY MI
49770-2212
US

IV. Provider business mailing address

416 CONNABLE AVE
PETOSKEY MI
49770-2212
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-4000
  • Fax: 231-487-4552
Mailing address:
  • Phone: 231-487-7684
  • Fax: 231-487-7721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number StateMI

VIII. Authorized Official

Name: MICHAEL PRUSAITIS
Title or Position: CFO
Credential:
Phone: 559-450-3375