Provider Demographics
NPI:1366522146
Name:KALEVA MEDICAL CENTER
Entity type:Organization
Organization Name:KALEVA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:BLISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-362-2777
Mailing Address - Street 1:9061 AURA ST
Mailing Address - Street 2:
Mailing Address - City:KALEVA
Mailing Address - State:MI
Mailing Address - Zip Code:49645-9678
Mailing Address - Country:US
Mailing Address - Phone:231-362-2777
Mailing Address - Fax:
Practice Address - Street 1:9061 AURA STREET
Practice Address - Street 2:
Practice Address - City:KALEVA
Practice Address - State:MI
Practice Address - Zip Code:49645-0141
Practice Address - Country:US
Practice Address - Phone:231-362-2777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI233918Medicare Oscar/Certification