Provider Demographics
NPI:1801162649
Name:THUNDER BAY COMMUNITY HEALTH SERVICE, INC
Entity type:Organization
Organization Name:THUNDER BAY COMMUNITY HEALTH SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-724-4583
Mailing Address - Street 1:P.O. BOX 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-354-2197
Mailing Address - Fax:989-356-6524
Practice Address - Street 1:555 N BRADLEY HWY
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779
Practice Address - Country:US
Practice Address - Phone:989-734-2151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicare PIN