Provider Demographics
NPI:1376750091
Name:EAST JORDAN FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:EAST JORDAN FAMILY HEALTH CENTER
Other - Org Name:BELLAIRE FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-536-2206
Mailing Address - Street 1:307 E CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49615-9707
Mailing Address - Country:US
Mailing Address - Phone:231-533-8649
Mailing Address - Fax:
Practice Address - Street 1:307 E CAYUGA ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49615-9707
Practice Address - Country:US
Practice Address - Phone:231-533-8649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231916Medicare Oscar/Certification
MI0A56344Medicare PIN