1083658140 NPI number — COMMUNITY MEMORIAL HOSPITAL

Table of content: (NPI 1083658140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083658140 NPI number — COMMUNITY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY MEMORIAL HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHEBOYGAN MEMORIAL HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083658140
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 419
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEBOYGAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49721-0419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-627-5601
Provider Business Mailing Address Fax Number:
231-627-1471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
748 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEBOYGAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49721-2220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-627-5601
Provider Business Practice Location Address Fax Number:
231-627-1471
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ENO
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BOARD
Authorized Official Telephone Number:
231-627-7111

Provider Taxonomy Codes

  • Taxonomy code: 282NR1301X , with the licence number:  160020 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00141 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1557767 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5170424 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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