Provider Demographics
NPI:1609837608
Name:MEDILODGE OF STERLING LLC
Entity Type:Organization
Organization Name:MEDILODGE OF STERLING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-752-5008
Mailing Address - Street 1:64500 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2583
Mailing Address - Country:US
Mailing Address - Phone:586-752-5008
Mailing Address - Fax:586-752-7609
Practice Address - Street 1:500 S SCHOOL RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:MI
Practice Address - Zip Code:48659-9799
Practice Address - Country:US
Practice Address - Phone:989-654-2496
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI064010314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS9501OtherBLUE CROSS OF MICHIGAN
MI4151193Medicaid
MI235416Medicare ID - Type Unspecified