Basic Information
| Provider Information | |||||||||
| NPI: | 1124055009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CENTER OF BRANCH COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 274 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490362041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 274 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | DEGROOT | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 5172795489 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 120010 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 120010 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 213E00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 208D00000X | 120010 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0A26057 | 01 | MI | BCBS MULTI SPECIALITY # | OTHER |