Provider Demographics
NPI:1346373065
Name:HASTINGS ORTHOPEDIC CLINIC PC
Entity Type:Organization
Organization Name:HASTINGS ORTHOPEDIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLENBARGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-945-4966
Mailing Address - Street 1:840 COOK RD
Mailing Address - Street 2:PO BOX 290
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-9616
Mailing Address - Country:US
Mailing Address - Phone:269-945-9520
Mailing Address - Fax:269-945-3368
Practice Address - Street 1:840 COOK RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-9616
Practice Address - Country:US
Practice Address - Phone:269-945-9520
Practice Address - Fax:269-945-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035154207X00000X
MI5101012880207X00000X
MI5101013049208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114206086Medicaid
MI5201000567OtherSUE BCBS
MI5101012880OtherJLH BSBS
MI5501012232OtherJENNY BCBS
MI101378087Medicaid
MI114316909Medicaid
MI200Z800130OtherKSM BCBS
MI5101013049OtherESL BCBS
MI0N82650004Medicare ID - Type UnspecifiedJLH MCR
MI0N82650003Medicare ID - Type UnspecifiedESL MCR
MI114206086Medicaid
MI5101013049OtherESL BCBS
MI200Z800130OtherKSM BCBS
MI5501012232OtherJENNY BCBS
MI0N82650005Medicare ID - Type UnspecifiedMARI MCR