Provider Demographics
NPI:1114278140
Name:MIDMICHIGAN HEALTH SERVICES
Entity Type:Organization
Organization Name:MIDMICHIGAN HEALTH SERVICES
Other - Org Name:MIDMICHIGAN MEDICAL OFFICES-BEAVERTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:RASCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:989-422-5122
Mailing Address - Street 1:9249 W LAKE CITY RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9602
Mailing Address - Country:US
Mailing Address - Phone:989-422-5122
Mailing Address - Fax:989-422-4378
Practice Address - Street 1:439 S ROSS ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:MI
Practice Address - Zip Code:48612-9101
Practice Address - Country:US
Practice Address - Phone:989-246-3500
Practice Address - Fax:989-246-3519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G27604Medicare PIN
MI231987Medicare PIN