Healthcare Provider Details

I. General information

NPI: 1184905796
Provider Name (Legal Business Name): MCLAREN BAY REGION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 PROGRESS ST SUITE A, BLDG A
WEST BRANCH MI
48661
US

IV. Provider business mailing address

559 PROGRESS ST SUITE A, BLDG A
WEST BRANCH MI
48661-9399
US

V. Phone/Fax

Practice location:
  • Phone: 989-345-0945
  • Fax: 989-345-2831
Mailing address:
  • Phone: 989-345-0945
  • Fax: 989-345-2831

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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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