Provider Demographics
NPI:1285465633
Name:MICHIGAN MASONIC HOME
Entity type:Organization
Organization Name:MICHIGAN MASONIC HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH INFORMATION SERVICES/CLINIC
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-466-3864
Mailing Address - Street 1:1200 WRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1133
Mailing Address - Country:US
Mailing Address - Phone:989-466-3864
Mailing Address - Fax:989-463-8921
Practice Address - Street 1:1200 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1133
Practice Address - Country:US
Practice Address - Phone:989-466-3864
Practice Address - Fax:989-463-8921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty