Provider Demographics
NPI:1497751309
Name:KALKASKA MEMORIAL HEALTH CENTER
Entity Type:Organization
Organization Name:KALKASKA MEMORIAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROGOLS
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE
Authorized Official - Phone:231-258-7501
Mailing Address - Street 1:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-0916
Mailing Address - Country:US
Mailing Address - Phone:231-935-6181
Mailing Address - Fax:
Practice Address - Street 1:419 S CORAL ST
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646
Practice Address - Country:US
Practice Address - Phone:231-935-6181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI275N00000X, 282N00000X, 282NC0060X, 282NR1301X, 314000000X, 341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
No282N00000XHospitalsGeneral Acute Care Hospital
No282NR1301XHospitalsGeneral Acute Care HospitalRural
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00211OtherBLUE CROSS HOSPITAL
MI15211OtherBLUE CROSS LTC PRIMARY
MA09553OtherBLUE CROSS LTC SECONDARY
MI1556877Medicaid
MI23D0651073OtherCLIA
MI5170952Medicaid
MI1556877Medicaid
MI15211OtherBLUE CROSS LTC PRIMARY
MI5170952Medicaid
MI23D0651073OtherCLIA
MI235407Medicare ID - Type UnspecifiedLONG TERM CARE