Provider Demographics
NPI:1114064193
Name:HERRICK MEDICAL CENTER
Entity Type:Organization
Organization Name:HERRICK MEDICAL CENTER
Other - Org Name:HERRICK MEMORIAL HOSPITAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:JAKACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-265-0900
Mailing Address - Street 1:500 E POTTAWATAMIE ST
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-2018
Mailing Address - Country:US
Mailing Address - Phone:517-424-3000
Mailing Address - Fax:517-265-0496
Practice Address - Street 1:500 E POTTAWATAMIE ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-2018
Practice Address - Country:US
Practice Address - Phone:517-424-3000
Practice Address - Fax:517-265-0496
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERRICK MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-31
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104806OtherCARE CHOICE & PREFER CHOI
MI5170836Medicaid
MIH04405OtherM-CARE
MI06088OtherPARAMOUNT
MI00085OtherBCBS
MI1556080Medicaid
MIH04405OtherM-CARE
OH23S120Medicare Oscar/Certification