Provider Demographics
NPI:1467788018
Name:MCLAREN PORT HURON
Entity Type:Organization
Organization Name:MCLAREN PORT HURON
Other - Org Name:PORT HURON HOSPITAL PHYSICIAN GRP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOLTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-989-3749
Mailing Address - Street 1:1221 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3511
Mailing Address - Country:US
Mailing Address - Phone:810-984-5156
Mailing Address - Fax:
Practice Address - Street 1:1209 RICHARDSON ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3548
Practice Address - Country:US
Practice Address - Phone:810-984-5156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEB086434101Y00000X
MIAG6437291041C0700X
MILK0344561041C0700X
MIRM0884381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7509106270OtherBCBS
MI0M85900Medicare PIN