Basic Information
Provider Information | |||||||||
NPI: | 1174749170 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRONSON SOUTH HAVEN HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRONSON MEDICAL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 601 JOHN ST | ||||||||
Address2: | BOX 42 | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490075341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693418419 | ||||||||
FaxNumber: | 2693418913 | ||||||||
Practice Location | |||||||||
Address1: | 950 S BAILEY AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH HAVEN | ||||||||
State: | MI | ||||||||
PostalCode: | 490908744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2696375271 | ||||||||
FaxNumber: | 2696392818 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2007 | ||||||||
LastUpdateDate: | 09/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EAST | ||||||||
AuthorizedOfficialFirstName: | REBECCA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | SVP, CFO | ||||||||
AuthorizedOfficialTelephone: | 2693416000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 261QU0200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282N00000X | 800020 | MI | N |   | Hospitals | General Acute Care Hospital |   | 207Q00000X | 1060000042 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 700H06003 | 01 | MI | BCBS GROUP NUMBER | OTHER | 800020 | 01 | MI | LICENSE NUMBER | OTHER |