Provider Demographics
NPI:1376597807
Name:MHSN ROSCOMMON MPCA
Entity Type:Organization
Organization Name:MHSN ROSCOMMON MPCA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-348-5461
Mailing Address - Street 1:PO BOX 647
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-0647
Mailing Address - Country:US
Mailing Address - Phone:989-348-1040
Mailing Address - Fax:
Practice Address - Street 1:234 LAKE ST
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-9203
Practice Address - Country:US
Practice Address - Phone:989-275-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOG21003OtherBC/BS MICHIGAN
MI0M6100Medicare PIN