Provider Demographics
NPI:1194767996
Name:STATE OF MICHIGAN OFFICE OF FINANCIAL MANAGEMENT
Entity type:Organization
Organization Name:STATE OF MICHIGAN OFFICE OF FINANCIAL MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEFERICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-335-0499
Mailing Address - Street 1:PO BOX 30437
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-7937
Mailing Address - Country:US
Mailing Address - Phone:517-241-5544
Mailing Address - Fax:517-335-6995
Practice Address - Street 1:2040 CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723
Practice Address - Country:US
Practice Address - Phone:989-672-9261
Practice Address - Fax:989-673-6749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
283Q00000X, 333600000X
MI53010005593336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2040745OtherPK
MI1758845Medicaid
0G96036Medicare PIN
234025Medicare Oscar/Certification
0G96037Medicare PIN