MEDICARE: THUNDER BAY CLINIC MANAGEMENT INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	BB012930	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790746964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THUNDER BAY CLINIC MANAGEMENT INC

Provider Business Mailing Address
First Line	:	1065 US 23 NORTH
Second Line	:
City	:	ALPENA
State	:	MI
Zip	:	49707
Country	:	US
Telephone Number	:	989-354-0607
Fax Number	:	989-356-6710

Provider Business Practice Location Address
First Line	:	1065 US 23 NORTH
Second Line	:
City	:	ALPENA
State	:	MI
Zip	:	49707
Country	:	US
Telephone Number	:	989-354-0607
Fax Number	:	989-356-6710

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JANE E HARDIES
Credential	:
Telephone Number	:	989-354-0607

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	06/25/2010

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