NPIMap

Organization Active NPI

Midmichigan Health Services

Doing business as Midmichigan Medical Offices-Beaverton

  • Federally Qualified Health Center (FQHC)
  • Beaverton, MI
National Provider Identifier
1114278140
Registry record updated May 20, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MIDMICHIGAN HEALTH SERVICES
Doing business as
Midmichigan Medical Offices-Beaverton
Practice address
439 S Ross St
Beaverton, MI 48612-9101
Phone
(989) 246-3500
Fax
(989) 246-3519
NPI assigned
Oct 1, 2012
Last updated
May 20, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 20, 2014

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

Authorized official

Name
James P Raschke, MBA
Title
Executive Director
Phone
(989) 422-5122

Specialties & licenses 1

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

Addresses

Primary practice location

439 S Ross St
Beaverton, MI 48612-9101

Mailing address

9249 W Lake City Rd
Houghton Lake, MI 48629-9602
Phone (989) 422-5122

Other names 1

  • MIDMICHIGAN MEDICAL OFFICES-BEAVERTON Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040130001007 MI Part B Supplier - Clinic/Group Practice 7911800495 Receives reassigned benefits from 38 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Beaverton, MI; Houghton Lake, MI; Midland, MI; Roscommon, MI; West Branch, MI
O20121025000113 MI Part A Provider - Federally Qualified Health Center (FQHC) 7911800495 Practice locations: Beaverton, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1114278140. Details of each certification follow.

Federally qualified health center certification: CCN 231987

Legal name
MIDMICHIGAN HEALTH SERVICES
Doing business as
MIDMICHIGAN MEDICAL OFFICES BEAVERTON
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 7, 2012
Last certification
Dec 7, 2012
Ownership / control type
For profit – corporation
Organization structure
OtherNon-profit
Enrollment address
439 S Ross St
Beaverton, MI 48612-9101

Other NPIs with the same Medicare PAC ID 6

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

Other NPIs on the same Medicare enrollment 5

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2036102Midmichigan Medical Offices Beaverton439 S Ross Street, Beaverton, MI 48612Certificate of waiverJan 31, 2028

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 19

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

NameRoleSinceShare
Dawn M Lacasse Individual Corporate DirectorBoard of Directors Member Jan 1, 2007
Deborah S Vanwert Individual Corporate DirectorBoard of Directors Member Jan 1, 2010
Raymond H Stover Individual Corporate DirectorBoard of Directors Member Jan 1, 2012
Frederick F Roemer Individual Corporate DirectorBoard of Directors Member Jan 1, 2005
Edward F Stern Individual Corporate DirectorBoard of Directors Member Jan 1, 2023 100%
Shannon E Phelps Individual Corporate DirectorBoard of Directors Member Jan 1, 2012
James P Raschke Individual Corporate OfficerCeo Apr 1, 2024 100%
Bryan R Cross Individual Corporate DirectorBoard of Directors Member Jan 1, 2023 100%
William Collin Individual Corporate OfficerCfo Jan 1, 2016 100%
Jeffrey B Fossitt Individual Corporate DirectorBoard of Directors Member Jan 1, 1990
Thomas J Moreau Individual Corporate DirectorBoard of Directors Member Jan 1, 2007
Robert Patrick McMorrow Individual Corporate OfficerChief Medical Officer Jul 22, 2019 100%
Lenard S Govitz Individual Corporate DirectorBoard of Directors Member Jan 1, 2020 100%
Melissa J Dunkle Individual Corporate OfficerCeo Sep 1, 2023
W-2 Managing Employee Sep 1, 2023
Gregory H Rogers Individual Corporate DirectorBoard of Directors Member Jan 1, 2016 100%
Jennifer Shamel Individual Corporate OfficerCoo Dec 1, 2020 100%
Midmichigan Health Services Organization, Houghton Lake, MI Created for acquisition, Non-profit 5% Or Greater Direct Ownership Interest Nov 1, 2012 100%
James C Bischoff Individual Corporate DirectorBoard of Directors Member Jan 1, 1997
Joseph Passalacqua Individual Corporate DirectorBoard of Directors Member Jan 1, 2020 100%

Owners & managing parties with NPI records 7

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

All facility ownership & control disclosures 2

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

FacilityTypeRoleSince
Coleman School Based Health CenterColeman, MI, CCN C71027 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Apr 9, 2024
Beaverton School Wellness CenterBeaverton, MI, CCN C71033 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%) Aug 27, 2024

Owned or controlled facilities with NPI records 2

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

Facilities with the same owner 2

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

Practitioners & affiliated clinicians

Practitioners 1

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.

NPI Registry JSON

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

{
    "created_epoch": "1349049600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1400544000000",
    "number": "1114278140",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9249 W LAKE CITY RD",
            "city": "HOUGHTON LAKE",
            "state": "MI",
            "postal_code": "486299602",
            "telephone_number": "989-422-5122",
            "fax_number": "989-422-4378"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "439 S ROSS ST",
            "city": "BEAVERTON",
            "state": "MI",
            "postal_code": "486129101",
            "telephone_number": "989-246-3500",
            "fax_number": "989-246-3519"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIDMICHIGAN HEALTH SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-01",
        "last_updated": "2014-05-20",
        "status": "A",
        "authorized_official_last_name": "RASCHKE",
        "authorized_official_first_name": "JAMES",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "989-422-5122",
        "authorized_official_credential": "MBA"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MIDMICHIGAN MEDICAL OFFICES-BEAVERTON",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Beaverton, MI

Sources for this page

Verify at the official NPI Registry.