Provider Demographics
NPI:1851767370
Name:MID-MICHIGAN DISTRICT HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:MID-MICHIGAN DISTRICT HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:MARI (JOHN)
Authorized Official - Last Name:BRADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:RS MS
Authorized Official - Phone:989-831-3640
Mailing Address - Street 1:615 N STATE ST
Mailing Address - Street 2:STE 2
Mailing Address - City:STANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48888-9702
Mailing Address - Country:US
Mailing Address - Phone:989-831-5237
Mailing Address - Fax:989-831-5522
Practice Address - Street 1:615 N STATE ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:MI
Practice Address - Zip Code:48888-9702
Practice Address - Country:US
Practice Address - Phone:989-831-5237
Practice Address - Fax:989-831-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4074187185207Q00000X
207Q00000X, 2083P0901X
MI43010780762083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301078076OtherPHYSICIAN LICENSE
MI5100715Medicaid
MI4632776Medicaid
MI2327700Medicaid
MI4704187185OtherNURSE PRACTITIONER