Provider Demographics
NPI:1083772826
Name:HURON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:HURON MEMORIAL HOSPITAL
Other - Org Name:MCLAREN THUMB REGION - PORT AUSTIN CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-803-7127
Mailing Address - Street 1:1100 S VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9615
Mailing Address - Country:US
Mailing Address - Phone:989-269-9521
Mailing Address - Fax:989-269-5260
Practice Address - Street 1:1100 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9615
Practice Address - Country:US
Practice Address - Phone:989-269-9521
Practice Address - Fax:989-269-5260
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HURON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-05
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRL040876207Q00000X
MIRD002414363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238587Medicare ID - Type Unspecified