Basic Information
| Provider Information | |||||||||
| NPI: | 1780952549 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHREACH HEALTHCARE, LLC | ||||||||
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| OtherOrganizationName: | MENOMINEE MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MENOMINEE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498583027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2011 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | HIPKE | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7157322078 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHREACH HEALTHCARE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 291U00000X | 23D09382233 | MI | N | Laboratories | Clinical Medical Laboratory | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 23D0382233 | 01 | MI | CLINIC CLIA | OTHER | 23-3861 | 01 | MI | RURAL HEALTH | OTHER |