Provider Demographics
NPI:1891723128
Name:DICKINSON COUNTY HEALTHCARE SYSTEM
Entity Type:Organization
Organization Name:DICKINSON COUNTY HEALTHCARE SYSTEM
Other - Org Name:DICKINSCON CONVENIENT CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-774-1313
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-0549
Mailing Address - Country:US
Mailing Address - Phone:906-774-1313
Mailing Address - Fax:906-776-5639
Practice Address - Street 1:1721 S STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-3637
Practice Address - Country:US
Practice Address - Phone:906-774-1313
Practice Address - Fax:906-776-5639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43058200Medicaid
MI16126OtherBCBS FACILITY CODE RHC
MI16126OtherBCBS FACILITY CODE RHC
MI0N87160Medicare PIN
MI0B26002Medicare PIN
WI43058200Medicaid