Basic Information
| Provider Information | |||||||||
| NPI: | 1164508891 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHARLEVOIX AREA HOSPITAL SWING BED | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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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: | 14700 LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474024 | ||||||||
| FaxNumber: | 2315478088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 03/18/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILHELM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2315478511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | MI | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 5170308 | 05 | MI | MEDICAID |