Provider Demographics
NPI:1295845766
Name:MYMICHIGAN MEDICAL CENTER SAULT
Entity Type:Organization
Organization Name:MYMICHIGAN MEDICAL CENTER SAULT
Other - Org Name:MYMICHIGAN DIALYSIS SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KALCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-635-4456
Mailing Address - Street 1:500 OSBORN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 OSBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2069
Practice Address - Country:US
Practice Address - Phone:906-253-1009
Practice Address - Fax:906-635-7872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI40-3501500Medicaid
232350Medicare Oscar/Certification