McLaren Central Michigan
Organization Active NPI Rural Health Clinic/Center · Petoskey, MI
NPI 1346862455 · NPPES record last updated Oct 21, 2021
Key facts
- NPI
- 1346862455
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- MCLAREN CENTRAL MICHIGAN
- Practice address
- 560 W Mitchell St
Stes 125,160,170,185,300,400,505,560,M40,C80,C70,240
Petoskey, MI 49770-2275 - Phone
- (231) 487-2460
- Fax
- (231) 487-6596
- NPI assigned
- May 12, 2020
- Organization subpart
- No
Authorized official
- Name
- Tara Soules
- Title
- VP/Cfo
- Phone
- (989) 772-6818
Owners & managing parties with NPI records 3
-
Kyle Gilde, MD
Other NPIs with the same Medicare PAC ID 20
Corporate family (same tax ID) 42
Related certifications (CCN) 1
Facilities with the same owner 58
Practitioners 184
-
Christopher J Abood, M.D.
-
Chris W Akins, MD
-
Yousef Bader, MD
-
Theodore A Bash, D.O.
-
Mustafa Bdiwi, MD
-
Ryan Ber, MD
-
John A Blanchard, MD
-
Paul D Blanchard, M.D.
-
Kristine E. Bobish, D.O.
-
Tracy D Brady, M.D.
-
Taylor Ann Brenz, PA-C
-
Tammy Broz, FNP-BC
-
Rachel Chapko, PA-C
-
Irene F Connolly, M.D.
-
Elena Catherine Coppola, D.O.
-
Michael G Cotant, M.D.
-
Matthew Lawrence D'John, M.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 23D2175780 | McLaren Central Michigan | Certificate of waiver | Dec 1, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MI
Rural health clinic certification: CCN 238729
- Legal name
- MCLAREN CENTRAL MICHIGAN
- Doing business as
- MCLAREN NORTHERN MICHIGAN BURNS BUILDING
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Dec 18, 2020
- Last certification
- Dec 18, 2020
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Enrollment address
- 560 W Mitchell St Ste 240, 340, 125, 170
Ste 185, 300, 400, 505, 560, 250, M40, C80
Petoskey, MI 49770-2275 - Related CCNs
- 230080
All disclosed owners & managing parties 17
| Name | Role | Since | Share |
|---|---|---|---|
| Ashok Vashishta |
Corporate Director |
Feb 28, 2007 | |
| Douglas Ouellette |
Corporate Director |
Feb 1, 2016 | |
| Bryan Wieferich |
Corporate Director |
Mar 18, 2024 | |
| Pamela H Myler |
Corporate Director |
Feb 1, 2012 | |
| Robert David |
Corporate Officer |
Jan 17, 2022 | |
| Corporate Director |
Jan 17, 2022 | ||
| Operational/Managerial Control |
Jan 17, 2022 | ||
| Chad Grant |
Corporate Director |
Aug 7, 2021 | |
| Cindy Jacobs |
Corporate Director |
Mar 24, 2026 | |
| Matthew Romashko |
Corporate Director |
Jan 1, 2023 | |
| Erik Rodriguez |
Corporate Director |
Mar 18, 2024 | |
| Lori Rogers |
Corporate Director |
Mar 24, 2026 | |
| Philip a Incarnati |
Other |
Sep 30, 2010 | |
| Vicki Tuma |
Corporate Director |
Jun 21, 2021 | |
| Michael a Swirtz |
Corporate Director |
Feb 1, 2014 | |
| Daniel Boge |
Corporate Director |
Jan 1, 2009 | |
| Tara Soules |
Corporate Officer |
Mar 27, 2016 | |
| W-2 Managing Employee |
Mar 27, 2016 | ||
| McLaren Health Care Corporation |
5% Or Greater Direct Ownership Interest | Sep 30, 2010 | 100% |
| Kyle J Gilde |
Corporate Director |
Mar 24, 2026 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20201208001898 | MI | Part a Provider - Rural Health Clinic | 6103733092 | Practice locations: Petoskey, MI |
National Provider Directory
- Tax ID family
- McLaren Central Michigan
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
560 W Mitchell St
Stes 125,160,170,185,300,400,505,560,M40,C80,C70,240
Petoskey, MI 49770-2275
Mailing address
1221 South Dr
Mt Pleasant, MI 48858-3257
Phone (989) 772-6700
Other providers in Petoskey, MI
- Dennis Edward McGeath
- Vaughn A McGraw
- Matthew McKelvey
- Holly Ann McKinney
- Mona McLain
- McLaren Central Michigan
- McLaren Central Michigan
- McLaren Central Michigan
- McLaren Central Michigan
- McLaren Health Management Group
All providers in Petoskey, MI · Rural Health Clinic/Center in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 21, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.