Provider Demographics
NPI:1639123623
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:ROCHARD
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 1:11899 M 32
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:MI
Practice Address - Zip Code:49709-9374
Practice Address - Country:US
Practice Address - Phone:989-785-4855
Practice Address - Fax:989-785-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F06016OtherMEDICARE BILL PAY TO
MI0F06016OtherMEDICARE BILL PAY TO
231829Medicare ID - Type Unspecified