Provider Demographics
NPI:1558506253
Name:INTERCARE COMMUNITY HEALTH NETWORK
Entity Type:Organization
Organization Name:INTERCARE COMMUNITY HEALTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:VELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSHOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-427-7937
Mailing Address - Street 1:50 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1246
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:269-427-5180
Practice Address - Street 1:870 COLFAX AVE
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-7409
Practice Address - Country:US
Practice Address - Phone:269-605-1060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-09
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHO6000Medicare PIN
231939Medicare Oscar/Certification