Provider Demographics
NPI:1730282237
Name:BARAGA COUNTY MEMORIAL HOSPITAL LTC
Entity type:Organization
Organization Name:BARAGA COUNTY MEMORIAL HOSPITAL LTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:TEMBREULL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:906-524-3321
Mailing Address - Street 1:770 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANSE
Mailing Address - State:MI
Mailing Address - Zip Code:49946-1126
Mailing Address - Country:US
Mailing Address - Phone:906-524-3300
Mailing Address - Fax:906-524-5466
Practice Address - Street 1:770 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-1126
Practice Address - Country:US
Practice Address - Phone:906-524-3300
Practice Address - Fax:906-524-5466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI073010314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI09823OtherBLUE CROSS
MI15204OtherBLUE CROSS
MI2000019Medicaid
MI09823OtherBLUE CROSS
MI15204OtherBLUE CROSS