Provider Demographics
NPI:1457680357
Name:PATHWAYS
Entity Type:Organization
Organization Name:PATHWAYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-233-1236
Mailing Address - Street 1:200 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4630
Mailing Address - Country:US
Mailing Address - Phone:906-233-1236
Mailing Address - Fax:906-233-1235
Practice Address - Street 1:200 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4630
Practice Address - Country:US
Practice Address - Phone:906-233-1236
Practice Address - Fax:906-233-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-24
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1724945Medicaid
MI1724945Medicaid
MION21670Medicare PIN
MI0N21650Medicare PIN