Provider Demographics
NPI:1891980306
Name:KALKASKA MEMORIAL HEALTH CENTER
Entity Type:Organization
Organization Name:KALKASKA MEMORIAL HEALTH CENTER
Other - Org Name:KALKASKA DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-258-3651
Mailing Address - Street 1:4062 W ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-8965
Mailing Address - Country:US
Mailing Address - Phone:231-935-5652
Mailing Address - Fax:231-935-7792
Practice Address - Street 1:415 2ND ST.
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646
Practice Address - Country:US
Practice Address - Phone:231-258-3680
Practice Address - Fax:231-258-3695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID8982OtherBCBSM PRIMARY
MI1891980306Medicaid
MI09417OtherBCBSM -SUPPLEMENTAL
MI1891980306Medicaid