1790867216 NPI number — MUNSON HEALTHCARE CHARLEVOIX HOSPITAL

Table of content: (NPI 1790867216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790867216 NPI number — MUNSON HEALTHCARE CHARLEVOIX HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MUNSON HEALTHCARE CHARLEVOIX 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:
6
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:
1790867216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
223 N PARK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOYNE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49712-1220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-582-5314
Provider Business Mailing Address Fax Number:
231-582-5338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 N PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOYNE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49712-1220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-582-5314
Provider Business Practice Location Address Fax Number:
231-582-5338
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KRUSZKA
Authorized Official First Name:
BONNIE
Authorized Official Middle Name:
Authorized Official Title or Position:
COO MUNSON PHYSICIAN NETWORK
Authorized Official Telephone Number:
231-935-4995

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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: 0A51004 . This is a "BCN FP PROFESSIONAL GRP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 31459366 . This is a "FIRST HEALTH FP GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 900001729 . This is a "PRIORITY HEALTH FP GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0A51004 . This is a "BLUE SHIELD FP GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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