Basic Information
| Provider Information | |||||||||
| NPI: | 1083658140 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHEBOYGAN MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 419 | ||||||||
| Address2: | |||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497210419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316275601 | ||||||||
| FaxNumber: | 2316271471 | ||||||||
| Practice Location | |||||||||
| Address1: | 748 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497212220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316275601 | ||||||||
| FaxNumber: | 2316271471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 09/15/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ENO | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BOARD | ||||||||
| AuthorizedOfficialTelephone: | 2316277111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 160020 | MI | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | 00141 | 01 | MI | BLUE CROSS | OTHER | 1557767 | 05 | MI | MEDICAID | 5170424 | 05 | MI | MEDICAID |