MEDICARE: THUNDER BAY COMMUNITY HEALTH SERVICE, 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	261QF0400X	Federally Qualified Health Center (FQHC)

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0F06016	OTHER	MI	MEDICARE BILL PAY TO

General Provider Information

NPI Number	:	1942253851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THUNDER BAY COMMUNITY HEALTH SERVICE, INC

Provider Business Mailing Address
First Line	:	PO BOX 427
Second Line	:
City	:	HILLMAN
State	:	MI
Zip	:	49746-0427
Country	:	US
Telephone Number	:	989-742-4583
Fax Number	:	989-742-4298

Provider Business Practice Location Address
First Line	:	15774 SATE STREET
Second Line	:
City	:	HILLMAN
State	:	MI
Zip	:	49746-0427
Country	:	US
Telephone Number	:	989-742-4583
Fax Number	:	989-742-4298

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MICHELLE STYMA
Credential	:
Telephone Number	:	989-742-4583

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	06/02/2015

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