Basic Information
| Provider Information | |||||||||
| NPI: | 1780722785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCLAREN BAY REGION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 COLUMBUS AVE | ||||||||
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| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487086831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898943000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1480 W CENTER RD STE 5 | ||||||||
| Address2: | |||||||||
| City: | ESSEXVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898954625 | ||||||||
| FaxNumber: | 9898954626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | JACKS PORTER | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9898943838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700Z946010 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |