Provider Demographics
NPI:1881655777
Name:MEDILODGE OF ST. CLAIR, INC.
Entity Type:Organization
Organization Name:MEDILODGE OF ST. CLAIR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-752-5008
Mailing Address - Street 1:64500 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4220 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:EAST CHINA
Practice Address - State:MI
Practice Address - Zip Code:48054-2200
Practice Address - Country:US
Practice Address - Phone:810-329-4736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-30
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI744040314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2630271Medicaid
MI09915OtherBLUE CROSS OF MICHIGAN
MI2630271Medicaid