Provider Demographics
NPI:1427045442
Name:MEDILODGE OF ST. CLAIR
Entity Type:Organization
Organization Name:MEDILODGE OF ST. CLAIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:STUEVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-329-4736
Mailing Address - Street 1:4220 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:EAST CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-2200
Mailing Address - Country:US
Mailing Address - Phone:810-329-4736
Mailing Address - Fax:810-329-6282
Practice Address - Street 1:4220 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2200
Practice Address - Country:US
Practice Address - Phone:810-329-4736
Practice Address - Fax:810-329-6282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI744040314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2630271Medicaid
MI2630271Medicaid
MI235370Medicare Oscar/Certification