Provider Demographics
NPI:1164410841
Name:ASCENSION ST JOSEPH HOSPITAL
Entity Type:Organization
Organization Name:ASCENSION ST JOSEPH HOSPITAL
Other - Org Name:ASCENSION ST JOSEPH HOSPITAL INTERNAL MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-362-9411
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0779
Mailing Address - Country:US
Mailing Address - Phone:989-362-6108
Mailing Address - Fax:989-362-0161
Practice Address - Street 1:295 MAPLE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9352
Practice Address - Country:US
Practice Address - Phone:989-362-6108
Practice Address - Fax:989-362-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
233986Medicare Oscar/Certification