Provider Demographics
NPI:1235208182
Name:STATE OF MICHIGAN
Entity Type:Organization
Organization Name:STATE OF MICHIGAN
Other - Org Name:MT PLEASANT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HOSPITAL - CNETERS
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-335-0263
Mailing Address - Street 1:P.O. BOX 30437
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-7937
Mailing Address - Country:US
Mailing Address - Phone:517-335-8245
Mailing Address - Fax:517-335-6995
Practice Address - Street 1:1400 W PICKARD ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-1364
Practice Address - Country:US
Practice Address - Phone:989-773-7921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-07
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301001112282E00000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2318687OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI2085384Medicaid
2318687OtherOTHER ID NUMBER