Basic Information
Provider Information | |||||||||
NPI: | 1285891473 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 MEDICAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | WATERVLIET | ||||||||
State: | MI | ||||||||
PostalCode: | 490989225 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2699838300 | ||||||||
FaxNumber: | 2694633581 | ||||||||
Practice Location | |||||||||
Address1: | 450 MEDICAL PARK DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | WATERVLIET | ||||||||
State: | MI | ||||||||
PostalCode: | 490988531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2694633111 | ||||||||
FaxNumber: | 2694633581 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2008 | ||||||||
LastUpdateDate: | 04/06/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CALHOUN | ||||||||
AuthorizedOfficialFirstName: | TIM | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE/CFO | ||||||||
AuthorizedOfficialTelephone: | 2699838300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 104947784 | 05 | MI |   | MEDICAID |