Provider Demographics
NPI:1255768529
Name:UPPER GREAT LAKES FAMILY HEALTH
Entity type:Organization
Organization Name:UPPER GREAT LAKES FAMILY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUTIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-346-3202
Mailing Address - Street 1:135 E M35
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-9160
Mailing Address - Country:US
Mailing Address - Phone:906-346-9668
Mailing Address - Fax:906-346-9113
Practice Address - Street 1:921 W SHARON AVE
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931-1921
Practice Address - Country:US
Practice Address - Phone:906-346-9667
Practice Address - Fax:906-346-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)