Basic Information
Provider Information | |||||||||
NPI: | 1043562762 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MUNISING MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 SANDPOINT RD | ||||||||
Address2: |   | ||||||||
City: | MUNISING | ||||||||
State: | MI | ||||||||
PostalCode: | 498621406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9063874338 | ||||||||
FaxNumber: | 9063872825 | ||||||||
Practice Location | |||||||||
Address1: | 1500 SANDPOINT RD | ||||||||
Address2: |   | ||||||||
City: | MUNISING | ||||||||
State: | MI | ||||||||
PostalCode: | 498621406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9063874110 | ||||||||
FaxNumber: | 9063872825 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2012 | ||||||||
LastUpdateDate: | 10/30/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALL | ||||||||
AuthorizedOfficialFirstName: | MELISSA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9063874110 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MUNISING MEMORIAL HOSPITAL ASSOCIATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4704294505 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 4301068824 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 4301050177 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 4301076662 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 4301095227 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207X00000X | 4301034044 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 261QR1300X | 1060000115 | MI | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 23-8650 | 01 | MI | RHC CERTIFICATION NUMBER (CMS) | OTHER | 1043562762 | 01 | MI | MEDICAID RHC NPI | OTHER |