Provider Demographics
NPI:1093044067
Name:MYMICHIGAN MEDICAL CENTER GLADWIN
Entity Type:Organization
Organization Name:MYMICHIGAN MEDICAL CENTER GLADWIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-246-6201
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 E CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-7003
Practice Address - Country:US
Practice Address - Phone:989-246-6201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYMICHIGAN MEDICAL CENTER GLADWIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-21
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-8641OtherMEDICARE PTAN