Basic Information
| Provider Information | |||||||||
| NPI: | 1326124058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PHYSICIAN CLINIC OF CHARLEVOIX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14709 W. UPRIGHT STREET | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315476519 | ||||||||
| FaxNumber: | 2315475404 | ||||||||
| Practice Location | |||||||||
| Address1: | 14709 W. UPRIGHT STREET | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315476519 | ||||||||
| FaxNumber: | 2315475404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 03/17/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILHELM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2315474024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0A51041 | 01 | MI | BLUE SHIELD | OTHER |