| Contacts | Authorizing Official | Update | Change Request | Rogols, Kevin
CEO
Kalkaska Memorial Health Center
2312587501 | Raymond, Andrew
CEO
Kalkaska Memorial Health Center
2312583651 | 3/19/2025 1:19 PM |
| Details | Last Recertification Date | Update | Recertification | 8/22/2023 3:59:26 PM | 8/21/2024 11:27:13 AM | 8/21/2024 11:27 AM |
| Medicaid Billing | Medicaid: Is Primary | Insert | Change Request | | False | 1/10/2024 2:24 PM |
| Medicaid Billing | Medicaid: Number | Insert | Change Request | | 1497751309 | 1/10/2024 2:24 PM |
| Medicaid Billing | Medicaid: State | Insert | Change Request | | MI | 1/10/2024 2:24 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1497751309 | 1/10/2024 2:24 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | MI | 1/10/2024 2:24 PM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2022 4:32:07 PM | 8/22/2023 3:59:26 PM | 8/22/2023 3:59 PM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2021 10:32:36 AM | 8/31/2022 4:32:07 PM | 8/31/2022 4:32 PM |
| Contacts | Primary Contact | Update | Change Request | Smith, Teresa
Medical Staff Services Manager
Kalkaska Memorial Health Center
2312588053 | Whiting, Chandra
Executive Assistant
Kalkaska Memorial Health Center
2312587502 | 7/6/2022 11:41 AM |
| Contacts | Primary Contact | Update | Profile Change Request | Smith, Teresa
Executive Assistant
Kalkaska Memorial Health Center
2312587502 | Smith, Teresa
Medical Staff Services Manager
Kalkaska Memorial Health Center
2312588053 | 3/3/2022 4:20 PM |
| Details | Last Recertification Date | Update | Recertification | 8/18/2020 8:35:41 AM | 8/20/2021 10:32:36 AM | 8/20/2021 10:32 AM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2019 10:00:29 AM | 8/18/2020 8:35:41 AM | 8/18/2020 8:35 AM |
| Details | Last Recertification Date | Update | Recertification | 8/21/2018 4:12:43 PM | 8/26/2019 10:00:29 AM | 8/26/2019 10:00 AM |
| Details | Last Recertification Date | Update | Recertification | 11/6/2017 1:14:46 PM | 8/21/2018 4:12:43 PM | 8/21/2018 4:12 PM |
| Details | Last Recertification Date | Update | Recertification | 10/24/2017 10:35:21 AM | 11/6/2017 1:14:46 PM | 11/6/2017 1:14 PM |
| Details | Last Recertification Date | Update | Recertification | 8/17/2016 12:00:00 AM | 10/24/2017 10:35:21 AM | 10/24/2017 10:35 AM |
| Contacts | Primary Contact | Update | | Smith, Teresa
Executive Assistant
2312587502 | Smith, Teresa
Executive Assistant
Kalkaska Memorial Health Center
2312587502 | 10/16/2017 4:00 PM |
| Contacts | Authorizing Official | Update | | Rogols, Kevin
CEO
2312587501 | Rogols, Kevin
CEO
Kalkaska Memorial Health Center
2312587501 | 10/16/2017 3:54 PM |
| Contacts | Authorizing Official | Update | | AUSTIN, JAMES D.
CEO
2312587501 | Rogols, Kevin
CEO
2312587501 | 4/18/2017 12:25 PM |
| Addresses | Main Address | Insert | | |
419 S. CORAL ST.
KALKASKA, MI 49646 | 8/17/2016 8:09 AM |
| Contacts | Primary Contact | Update | | ATWOOD, SHEILA
administrative Director Patient Care Services
2312587505 | Smith, Teresa
Executive Assistant
2312587502 | 8/17/2016 8:09 AM |
| Details | Last Recertification Date | Update | | 8/26/2015 12:00:00 AM | 8/17/2016 12:00:00 AM | 8/17/2016 8:09 AM |
| Details | Last Recertification Date | Update | | 8/6/2014 12:00:00 AM | 8/26/2015 12:00:00 AM | 8/26/2015 3:17 PM |
| Addresses | Billing Address | Insert | | | KALKASKA MEMORIAL HEALTH CENTER
P.O BOX 916
TRAVERSE CITY, MI 49685 | 1/28/2015 8:04 AM |
| Contacts | Primary Contact | Insert | | | ATWOOD, SHEILA
administrative Director Patient Care Services
2312587505 | 12/10/2014 9:56 AM |
| Details | Last Recertification Date | Update | | 8/19/2013 8:27:59 AM | 8/6/2014 12:00:00 AM | 8/6/2014 9:07 AM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 8/19/2013 8:27:59 AM | 8/19/2013 8:27 AM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 5/7/2012 9:26 AM |
| Contacts | Authorizing Official | Insert | | | AUSTIN, JAMES D.
CEO
2312587501 | 3/16/2011 6:22 PM |
| Details | Last Recertification Date | Insert | | | | 8/31/2010 10:32 AM |
| Details | Grant Number | Insert | | | | 8/31/2010 10:32 AM |
| Details | 340B ID | Insert | | | CAH231301-00 | 8/31/2010 10:32 AM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 8/31/2010 10:32 AM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 8/31/2010 10:32 AM |
| Details | Medicare Provider Number | Insert | | | 231301 | 8/31/2010 10:32 AM |
| Details | Entity Name | Insert | | | KALKASKA MEMORIAL HEALTH CENTER | 8/31/2010 10:32 AM |
| Details | Program Code | Insert | | | CAH | 8/31/2010 10:32 AM |
| Details | Entity Subname | Insert | | | | 8/31/2010 10:32 AM |
| Dates | Participating Approval Date | Insert | | | 8/27/2010 12:00:00 AM | 8/31/2010 10:32 AM |
| Details | State | Insert | | | Active | 8/31/2010 10:32 AM |
| Dates | Registration Date | Insert | | | 8/26/2010 12:00:00 AM | 8/31/2010 10:32 AM |
| Dates | Signed By Date | Insert | | | 8/26/2010 12:00:00 AM | 8/31/2010 10:32 AM |
| Dates | Start Date | Insert | | | 8/31/2010 12:00:00 AM | 8/31/2010 10:32 AM |
| Terminations | Termination Comments | Insert | | | | 8/31/2010 10:32 AM |
| Terminations | Termination Date | Insert | | | | 8/31/2010 10:32 AM |
| Terminations | Termination Effective Date | Insert | | | | 8/31/2010 10:32 AM |
| Terminations | Termination Reason | Insert | | | | 8/31/2010 10:32 AM |