Provider Demographics
NPI:1326124322
Name:COUNTY OF GRAND TRAVERSE
Entity Type:Organization
Organization Name:COUNTY OF GRAND TRAVERSE
Other - Org Name:GRAND TRAVERSE MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KORVYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:231-932-3010
Mailing Address - Street 1:1000 PAVILIONS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3198
Mailing Address - Country:US
Mailing Address - Phone:231-932-3000
Mailing Address - Fax:231-932-3009
Practice Address - Street 1:1000 PAVILIONS CIRCLE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3198
Practice Address - Country:US
Practice Address - Phone:231-932-3000
Practice Address - Fax:231-932-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI288510314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3470207-61Medicaid
MI235088Medicare Oscar/Certification