Basic Information
| Provider Information | |||||||||
| NPI: | 1154440394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARSON CITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MSG BCBS GROUP MD DO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 406 E ELM ST | ||||||||
| Address2: | PO BOX 730 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488119693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843971 | ||||||||
| FaxNumber: | 9895846734 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488119693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843971 | ||||||||
| FaxNumber: | 9895846734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BUSLEPP | ||||||||
| AuthorizedOfficialFirstName: | NATALIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MSG DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9895843971 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.