Provider Demographics
NPI: | 1013183060 |
---|---|
Name: | KALKASKA MEMORIAL HEALTH CENTER |
Entity Type: | Organization |
Organization Name: | KALKASKA MEMORIAL HEALTH CENTER |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | KEVIN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ROGOLS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | FACHE |
Authorized Official - Phone: | 231-258-7501 |
Mailing Address - Street 1: | PO BOX 916 |
Mailing Address - Street 2: | |
Mailing Address - City: | TRAVERSE CITY |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 49685-0916 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 419 S CORAL ST |
Practice Address - Street 2: | |
Practice Address - City: | KALKASKA |
Practice Address - State: | MI |
Practice Address - Zip Code: | 49646-2503 |
Practice Address - Country: | US |
Practice Address - Phone: | 231-258-7500 |
Practice Address - Fax: | 231-258-7527 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-04-30 |
Last Update Date: | 2021-09-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
No | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
700D060020 | Other | BLUE CARE NETWORK | |
MI | 700D060020 | Other | BLUE CROSS BLUE SHIELD OF MICHIGAN |
0D06002 | Medicare PIN |