Provider Demographics
NPI:1841436128
Name:BANGOR HEALTH CENTER
Entity type:Organization
Organization Name:BANGOR HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LR
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-567-5574
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:801 HAZEN STREET, SUITE C.
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0249
Mailing Address - Country:US
Mailing Address - Phone:269-657-5574
Mailing Address - Fax:269-657-3474
Practice Address - Street 1:803 WEST ARLINGTON STREET
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1108
Practice Address - Country:US
Practice Address - Phone:269-427-6810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAN BUREN COMMUNITY MENTAL HEALTH AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-17
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI50-0-H01075-0OtherBLUE CROSS BLUE SHIELD OF MICHIGAN