Provider Demographics
NPI:1942257076
Name:CITY OF MANISTIQUE
Entity Type:Organization
Organization Name:CITY OF MANISTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-341-2134
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:MANISTIQUE
Mailing Address - State:MI
Mailing Address - Zip Code:49854-0515
Mailing Address - Country:US
Mailing Address - Phone:906-341-2134
Mailing Address - Fax:
Practice Address - Street 1:300 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MANISTIQUE
Practice Address - State:MI
Practice Address - Zip Code:49854-1216
Practice Address - Country:US
Practice Address - Phone:906-341-2134
Practice Address - Fax:906-341-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7710013416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3000078Medicaid
MI590G70001OtherBCBS PROVIDER ID#
MI=========OtherPRIVATE INSURANCES EIN#
MI3000078Medicaid