Provider Demographics
NPI:1629357090
Name:MCLAREN BAY REGION
Entity Type:Organization
Organization Name:MCLAREN BAY REGION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKS PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-894-3838
Mailing Address - Street 1:200 GRAND AVE
Mailing Address - Street 2:PO BOX 679
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-9571
Mailing Address - Country:US
Mailing Address - Phone:989-366-1000
Mailing Address - Fax:989-366-1002
Practice Address - Street 1:200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651
Practice Address - Country:US
Practice Address - Phone:989-366-1000
Practice Address - Fax:989-366-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty