Provider Demographics
NPI:1629107552
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:INTERIM CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-742-4583
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:989-742-4583
Mailing Address - Fax:989-742-4298
Practice Address - Street 1:15774 STATE STREET
Practice Address - Street 2:
Practice Address - City:HILLMAN
Practice Address - State:MI
Practice Address - Zip Code:49746
Practice Address - Country:US
Practice Address - Phone:989-742-4583
Practice Address - Fax:989-742-4298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F06016OtherMEDICARE BILL PAY TO
MI0F06016Medicare UPIN
MI0F060160Medicare PIN