Basic Information
| Provider Information | |||||||||
| NPI: | 1063598845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
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| OtherOrganizationName: | CHARLEVOIX AREA HOSPITAL CRNA GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14700 LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474024 | ||||||||
| FaxNumber: | 2315478088 | ||||||||
| Practice Location | |||||||||
| Address1: | 14734 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474024 | ||||||||
| FaxNumber: | 2315478088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 03/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | WILHELM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2315474024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1001019 | 01 | MI | CRNA MCLAREN HEALTH PLAN | OTHER | 134141100 | 01 | MI | CRNA COMP CARRIER US POST | OTHER | 20139 | 01 | MI | CRNA PRIORITY HLTH PRO | OTHER | 0A51005 | 01 | MI | CRNA BCN PROFESSIONAL | OTHER |