Provider Demographics
NPI:1609435536
Name:THUNDER BAY COMMUNITY HEALTH SERVICE, INC
Entity Type:Organization
Organization Name:THUNDER BAY COMMUNITY HEALTH SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HEIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-354-2197
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-354-2197
Mailing Address - Fax:989-354-1957
Practice Address - Street 1:1033 W HURON AVE RM TB1
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-1428
Practice Address - Country:US
Practice Address - Phone:989-734-2052
Practice Address - Fax:989-734-7390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)