Basic Information
| Provider Information | |||||||||
| NPI: | 1164628426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OTSEGO MEMORIAL HOSPITAL RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 825 N CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897312100 | ||||||||
| FaxNumber: | 9897317929 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 N CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317708 | ||||||||
| FaxNumber: | 9897317929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAITLAND | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2319357840 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 282NR1301X | 238607 | MI | N | Hospitals | General Acute Care Hospital | Rural | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 23-8607 | 01 | CMS CERTIFICATION NUMBER | OTHER |