1174889604 NPI number — LAKESHORE COMMUNITY HOSPITAL, INC.

Table of content: (NPI 1174889604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174889604 NPI number — LAKESHORE COMMUNITY HOSPITAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE COMMUNITY HOSPITAL, INC.
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:
HART FAMILY MEDICAL CENTER
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:
1174889604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HART
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49420-1190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-873-5675
Provider Business Mailing Address Fax Number:
231-873-1825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HART
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49420-1190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-873-5675
Provider Business Practice Location Address Fax Number:
231-873-1825
Provider Enumeration Date:
04/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
VILLANUEVA
Authorized Official First Name:
YARA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC REIMBURSEMENT COORDINATOR
Authorized Official Telephone Number:
231-873-5675

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  AB033570 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: RO009698 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: PW011554 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: CU005544 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: JT003148 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3015197 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0F40011 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2963232 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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