Provider Demographics
NPI:1548497399
Name:ST. MARY'S OF MICHIGAN
Entity type:Organization
Organization Name:ST. MARY'S OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:THELEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD
Authorized Official - Phone:989-846-3407
Mailing Address - Street 1:805 W CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:MI
Mailing Address - Zip Code:48658-9526
Mailing Address - Country:US
Mailing Address - Phone:989-846-3407
Mailing Address - Fax:
Practice Address - Street 1:805 WEST CEDAR
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658
Practice Address - Country:US
Practice Address - Phone:989-846-3407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital