NPIMap

Organization Active NPI

McLaren Central Michigan

Doing business as McLaren Northern Michigan Family Medicine

  • Rural Health Clinic/Center
  • Petoskey, MI
National Provider Identifier
1760004733
Registry record updated Oct 25, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MCLAREN CENTRAL MICHIGAN
Doing business as
McLaren Northern Michigan Family Medicine
Practice address
820 Arlington Ave
Petoskey, MI 49770-2469
Phone
(231) 487-3955
Fax
(231) 487-1737
NPI assigned
May 13, 2020
Last updated
Oct 25, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 25, 2021

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

Authorized official

Name
Tara Soules
Title
VP/Cfo
Phone
(989) 772-6818

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

820 Arlington Ave
Petoskey, MI 49770-2469

Mailing address

1221 South Dr
Mt Pleasant, MI 48858-3257
Phone (989) 772-6700

Other names 1

  • McLaren Northern Michigan Family Medicine Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200819000768 MI Part A Provider - Rural Health Clinic 6103733092 Practice locations: Petoskey, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1760004733. Details of each certification follow.

Rural health clinic certification: CCN 238747

Legal name
MCLAREN CENTRAL MICHIGAN
Doing business as
MCLAREN NORTHERN MICHIGAN FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 30, 2020
Last certification
Dec 30, 2020
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
820 Arlington Ave
Ste 258
Petoskey, MI 49770-2469
Related CCNs
230080

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 20

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

View all 20

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
23D1057924McLaren Central Michigan820 Arlington Avenue, Petoskey, MI 49770Certificate of waiverAug 23, 2026

National Provider Directory

National Provider Directory
Tax ID family
McLaren Central Michigan43 organizations share this tax ID, including this one

Other organizations with this tax ID 42

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

View all 42

Ownership & related parties

All disclosed owners & managing parties 17

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

NameRoleSinceShare
Ashok Vashishta Individual Corporate DirectorDirector Feb 28, 2007
Douglas Ouellette Individual Corporate DirectorDirector Feb 1, 2016
Bryan Wieferich Individual Corporate DirectorTrustee Mar 18, 2024
Pamela H Myler Individual Corporate DirectorDirector Feb 1, 2012
Robert David Individual Corporate OfficerPresident/Ceo Jan 17, 2022
Corporate DirectorPresident/Ceo Jan 17, 2022
Operational/Managerial ControlPresident/Ceo Jan 17, 2022
Chad Grant Individual Corporate DirectorCoo & MHC Corp Designee Aug 7, 2021
Cindy Jacobs Individual Corporate DirectorTrustee Mar 13, 2023
Matthew Romashko Individual Corporate DirectorTrustee Feb 1, 2022
Erik Rodriguez Individual Corporate DirectorTrustee Mar 18, 2024
Lori Rogers Individual Corporate DirectorTrustee Mar 13, 2023
Philip a Incarnati Individual OtherMHC President/Ceo Sep 30, 2010
Vicki Tuma Individual Corporate DirectorTrustee Aug 26, 2021
Michael a Swirtz Individual Corporate DirectorDirector Feb 1, 2014
Daniel Boge Individual Corporate DirectorDirector Jan 1, 2009
Tara Soules Individual Corporate OfficerVP/Cfo Mar 27, 2016
W-2 Managing EmployeeVP/Cfo Mar 27, 2016
McLaren Health Care Corporation Organization, Grand Blanc, MI Corporation, Non-profit 5% Or Greater Direct Ownership Interest Sep 30, 2010 100%
Kyle J Gilde Individual Corporate DirectorTrustee Mar 24, 2026

Owners & managing parties with NPI records 3

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

Facilities with the same owner 58

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

View all 58

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": "1589328000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1635120000000",
    "number": "1760004733",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1221 SOUTH DR",
            "city": "MT PLEASANT",
            "state": "MI",
            "postal_code": "488583257",
            "telephone_number": "989-772-6700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "820 ARLINGTON AVE",
            "city": "PETOSKEY",
            "state": "MI",
            "postal_code": "497702469",
            "telephone_number": "231-487-3955",
            "fax_number": "231-487-1737"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MCLAREN CENTRAL MICHIGAN",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-05-13",
        "last_updated": "2021-10-25",
        "certification_date": "2021-10-25",
        "status": "A",
        "authorized_official_last_name": "SOULES",
        "authorized_official_first_name": "TARA",
        "authorized_official_title_or_position": "VP/CFO",
        "authorized_official_telephone_number": "989-772-6818"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "McLaren Northern Michigan Family Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Petoskey, MI

Sources for this page

Verify at the official NPI Registry.