Basic Information
| Provider Information | |||||||||
| NPI: | 1558470567 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BALDWIN FAMILY HEALTH CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY HEALTH CARE WHITE CLOUD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493047984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317452743 | ||||||||
| FaxNumber: | 2317453690 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 E WILCOX AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE CLOUD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493498794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316895943 | ||||||||
| FaxNumber: | 2316891590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TATKO | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2317452743 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BALDWIN FAMILY HEALTH CARE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 700D360000 | 01 | MI | BCN | OTHER | 0D36000 | 01 | MI | BCBS | OTHER |