Provider Demographics
NPI:1720145303
Name:MYMICHIGAN MEDICAL CENTER SAULT
Entity Type:Organization
Organization Name:MYMICHIGAN MEDICAL CENTER SAULT
Other - Org Name:MYMICHIGAN COMMUNITY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KALCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-635-4460
Mailing Address - Street 1:500 OSBORN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1822
Mailing Address - Country:US
Mailing Address - Phone:906-635-4460
Mailing Address - Fax:
Practice Address - Street 1:509 OSBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2069
Practice Address - Country:US
Practice Address - Phone:906-635-4460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYMICHIGAN MEDICAL CENTER SAULT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238541Medicare Oscar/Certification