Provider Demographics
NPI:1447298849
Name:MIDMICHIGAN GLADWIN PINES
Entity type:Organization
Organization Name:MIDMICHIGAN GLADWIN PINES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT ACCOUNTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WRZESINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-633-1486
Mailing Address - Street 1:449 QUARTER ST
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-1918
Mailing Address - Country:US
Mailing Address - Phone:989-426-3430
Mailing Address - Fax:989-246-6331
Practice Address - Street 1:449 QUARTER ST
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-1918
Practice Address - Country:US
Practice Address - Phone:989-426-3430
Practice Address - Fax:989-246-6331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDMICHIGAN HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-04
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI264028314000000X
MI1070000264314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1996373Medicaid
MI09904OtherBCBSM
MI09904OtherBCBSM