Provider Demographics
NPI:1508993361
Name:MYMICHIGAN MEDICAL CENTER GLADWIN
Entity Type:Organization
Organization Name:MYMICHIGAN MEDICAL CENTER GLADWIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-246-6203
Mailing Address - Street 1:4000 WELLNESS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 QUARTER STREET
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-1959
Practice Address - Country:US
Practice Address - Phone:989-426-9286
Practice Address - Fax:989-839-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430B610020OtherBL SHIELD CRNA GROUP
MI0B66014Medicare ID - Type UnspecifiedCRNA GROUP WPS