NPIMap

Organization Active NPI

Upper Great Lakes Family Health Center

Doing business as Ice Lake Family Health Center

  • Federally Qualified Health Center (FQHC)
  • Iron River, MI
National Provider Identifier
1508289273
Registry record updated May 13, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
UPPER GREAT LAKES FAMILY HEALTH CENTER
Doing business as
Ice Lake Family Health Center
Practice address
1500 W Ice Lake Road
Iron River, MI 49935-8509
Phone
(906) 265-5378
Fax
(906) 372-3230
NPI assigned
Jan 30, 2014
Last updated
May 13, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 13, 2026

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

Authorized official

Name
Trevor Hodges
Title
Ceo
Phone
(906) 483-1846

Specialties & licenses 2

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

Addresses

Primary practice location

1500 W Ice Lake Road
Iron River, MI 49935-8509

Mailing address

135 E M35
Gwinn, MI 49841-9160
Phone (906) 265-5378

Other names 1

  • Ice Lake Family Health Center Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100629000853 MI Part B Supplier - Clinic/Group Practice 1951432384 Receives reassigned benefits from 63 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Menominee, MI; Marquette, MI; Gwinn, MI; Iron River, MI; East Lansing, MI; Calumet, MI; Hancock, MI
O20140424000004 MI Part A Provider - Federally Qualified Health Center (FQHC) 1951432384 Practice locations: Iron River, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508289273. Details of each certification follow.

Federally qualified health center certification: CCN 231035

Legal name
UPPER GREAT LAKES FAMILY HEALTH CENTER
Doing business as
ICE LAKE FAMILY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 21, 2014
Last certification
May 21, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 1, 2013 in MI
Enrollment address
1500 W Ice Lake Rd
Iron River, MI 49935-8509

Other NPIs with the same Medicare PAC ID 11

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

Other NPIs on the same Medicare enrollment 10

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
23D2079175Ice Lake Family Health Center1500 West Ice Lake Road, Iron River, MI 49935Certificate of waiverJun 10, 2028

National Provider Directory

National Provider Directory
Tax ID family
Upper Great Lakes Center18 organizations share this tax ID, including this one

Other organizations with this tax ID 17

Organizations that report the same tax identification number in the National Provider Directory.

View all 17

Locations

506 Campus Dr
Hancock, MI 49930
Phone (906) 483-1000

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Tanya Johnson Individual Corporate Officer Oct 28, 2020
Trevor Hodges Individual Corporate DirectorCfo Jan 1, 2020
W-2 Managing EmployeeCfo Jan 1, 2020
Mark Rouleau Individual Corporate Officer Nov 24, 2021
Stephen Vairo Individual Corporate Officer Oct 7, 2009
Donald Simila Individual Corporate OfficerCeo Sep 1, 2013 100%
W-2 Managing EmployeeCeo Sep 1, 2013
Kevin L Piggott Individual Corporate Officer Oct 31, 2018
Cathryn Beer Individual Corporate Officer Oct 26, 2016
Dianna Christenson Individual Corporate Officer Dec 4, 2013
Christopher Adams Individual Corporate Officer Jun 26, 2019
Julie Shaw Individual Corporate Officer Sep 25, 2019
Allen Mott Individual Corporate Officer Mar 28, 2018
Micah Stipech Individual Corporate Officer Mar 25, 2020

Practitioners & affiliated clinicians

Practitioners 5

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": "1391040000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1778630400000",
    "number": "1508289273",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "135 E M35",
            "city": "GWINN",
            "state": "MI",
            "postal_code": "498419160",
            "telephone_number": "906-265-5378",
            "fax_number": "906-372-3230"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 W ICE LAKE ROAD",
            "city": "IRON RIVER",
            "state": "MI",
            "postal_code": "499358509",
            "telephone_number": "906-265-5378",
            "fax_number": "906-372-3230"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "UPPER GREAT LAKES FAMILY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-01-30",
        "last_updated": "2026-05-13",
        "certification_date": "2026-05-13",
        "status": "A",
        "authorized_official_last_name": "HODGES",
        "authorized_official_first_name": "TREVOR",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "906-483-1846"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "MI",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ice Lake Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Ice Lake Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Iron River, MI

Sources for this page

Verify at the official NPI Registry.