NPIMap

Organization Active NPI

Bay Mills Indian Community

  • Federally Qualified Health Center (FQHC)
  • Brimley, MI
National Provider Identifier
1053592089
Registry record updated Jun 9, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
231839 Issued in MI
Legal business name
BAY MILLS INDIAN COMMUNITY
Practice address
12455 W Lakeshore Dr
Brimley, MI 49715-9319
Phone
(906) 248-5527
Fax
(906) 248-5765
NPI assigned
Nov 19, 2007
Last updated
Jun 9, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 9, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Audrey Breakie
Title
Health Director
Phone
(906) 248-8327

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 231839 MI Primary

Addresses

Primary practice location

12455 W Lakeshore Dr
Brimley, MI 49715-9319

Mailing address

12455 W Lakeshore Dr
Brimley, MI 49715-9319
Phone (906) 248-5527

Other identifiers 1

IdentifierTypeStateIssuer
1053592089MedicaidMI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040518000950 MI Part B Supplier - Clinic/Group Practice 8729079918 Receives reassigned benefits from 21 practitioners
2 other NPIs on this enrollment
Practice locations: Brimley, MI
O20100603000514 MI Part A Provider - Federally Qualified Health Center (FQHC) 8729079918 Practice locations: Brimley, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053592089. Details of each certification follow.

Federally qualified health center certification: CCN 231839

Legal name
BAY MILLS INDIAN COMMUNITY
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 1, 1993
Last certification
Jan 1, 1993
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
12455 W Lakeshore Dr
Brimley, MI 49715-9327

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Lucy Dewildt Individual Corporate DirectorHHS Health Director May 31, 2024 100%
Abby L Kaunisto Individual W-2 Managing Employee Jul 7, 2015
Bay Mills Indian Community Organization, Brimley, MI Operational/Managerial Control Jan 1, 1993

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Bay Mills Indian CommunitySault Sainte Marie, MI, CCN C71010 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Dec 13, 2023

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1195430400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1654732800000",
    "number": "1053592089",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12455 W LAKESHORE DR",
            "city": "BRIMLEY",
            "state": "MI",
            "postal_code": "497159319",
            "telephone_number": "906-248-5527",
            "fax_number": "906-248-5765"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12455 W LAKESHORE DR",
            "city": "BRIMLEY",
            "state": "MI",
            "postal_code": "497159319",
            "telephone_number": "906-248-5527",
            "fax_number": "906-248-5765"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BAY MILLS INDIAN COMMUNITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-11-19",
        "last_updated": "2022-06-09",
        "certification_date": "2022-06-02",
        "status": "A",
        "authorized_official_last_name": "BREAKIE",
        "authorized_official_first_name": "AUDREY",
        "authorized_official_title_or_position": "HEALTH DIRECTOR",
        "authorized_official_telephone_number": "906-248-8327"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MI",
            "license": "231839",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1053592089",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Brimley, MI

Sources for this page

Verify at the official NPI Registry.