Provider Demographics
NPI:1790746964
Name:THUNDER BAY CLINIC MANAGEMENT INC
Entity Type:Organization
Organization Name:THUNDER BAY CLINIC MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARDIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-354-0607
Mailing Address - Street 1:1065 US 23 NORTH
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707
Mailing Address - Country:US
Mailing Address - Phone:989-354-0607
Mailing Address - Fax:989-356-6710
Practice Address - Street 1:1065 US 23 NORTH
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707
Practice Address - Country:US
Practice Address - Phone:989-354-0607
Practice Address - Fax:989-356-6710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBB012930208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3438729Medicaid
G16756Medicare UPIN
MI3438729Medicaid