1407949191 NPI number — MUNSON HEALTHCARE MANISTEE HOSPITAL

Table of content: (NPI 1407949191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407949191 NPI number — MUNSON HEALTHCARE MANISTEE HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MUNSON HEALTHCARE MANISTEE 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:
Provider Other Organization Name Type Code:
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:
1407949191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1465 E PARKDALE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANISTEE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49660-9785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-398-1000
Provider Business Mailing Address Fax Number:
231-398-0364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1465 E PARKDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANISTEE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49660-9785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-398-1000
Provider Business Practice Location Address Fax Number:
231-398-0364
Provider Enumeration Date:
10/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT AMBULATORY CLINICS
Authorized Official Telephone Number:
231-935-7840

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 275N00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 510020 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4971251 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00198 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1556474 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5172278 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".