Provider Demographics
NPI:1497816342
Name:CORNELL HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:CORNELL HEALTH AND WELLNESS
Other - Org Name:CENTRAL MICHIGAN URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:989-773-3789
Mailing Address - Street 1:520 N MISSION ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-1828
Mailing Address - Country:US
Mailing Address - Phone:989-773-3789
Mailing Address - Fax:989-773-0558
Practice Address - Street 1:520 N MISSION ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-1828
Practice Address - Country:US
Practice Address - Phone:989-773-3789
Practice Address - Fax:989-773-0558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1326065913OtherNPI
MIP24692Medicare UPIN
MION89930Medicare ID - Type UnspecifiedGLADWIN FAMILY CARE CENTE
MIOM57650Medicare ID - Type UnspecifiedECI-WEST BRANCH REGIONAL