Basic Information
| Provider Information | |||||||||
| NPI: | 1346260692 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14700 LAKE SHORE DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474024 | ||||||||
| FaxNumber: | 2315478088 | ||||||||
| Practice Location | |||||||||
| Address1: | 14700 LAKE SHORE DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474024 | ||||||||
| FaxNumber: | 2315478088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 01/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | HEPLER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2319355000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNSON HEALTHCARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 150021 | MI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 1001019 | 01 | MI | NORTHERN HEALTH PLAN | OTHER | 134141100 | 01 | MI | COMP CARRIER US POSTAL SV | OTHER | 00095 | 01 | MI | BLUE CARE NETWORK | OTHER | 00095 | 01 | MI | BLUE CROSS HOSP | OTHER | 5170308 | 05 | MI | MEDICAID | 1557598 | 05 | MI | MEDICAID | 4286 | 01 | MI | PRIORITY HEALTH | OTHER |