Provider Demographics
NPI:1790179828
Name:MEADOW BROOK MEDICAL CARE FACILITY
Entity Type:Organization
Organization Name:MEADOW BROOK MEDICAL CARE FACILITY
Other - Org Name:MEADOW BROOK OUTPATIENT THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:231-533-8661
Mailing Address - Street 1:4543 S M 88 HWY
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49615-9109
Mailing Address - Country:US
Mailing Address - Phone:231-533-8661
Mailing Address - Fax:231-533-4841
Practice Address - Street 1:4543 S M 88 HWY
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49615-9109
Practice Address - Country:US
Practice Address - Phone:231-533-8661
Practice Address - Fax:231-533-4841
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEADOW BROOK MEDICAL CARE FACILITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-26
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI61-2085141Medicaid
MI235025Medicare UPIN