Basic Information
| Provider Information | |||||||||
| NPI: | 1417033143 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
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| OtherOrganizationName: | MULTI-SPECIALTY GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14700 LAKE SHORE DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474024 | ||||||||
| FaxNumber: | 2315478088 | ||||||||
| Practice Location | |||||||||
| Address1: | 14700 LAKE SHORE DRIVE | ||||||||
| Address2: | |||||||||
| City: | CHARLEVOIX | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2315474024 | ||||||||
| FaxNumber: | 2315478088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 03/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | WILHELM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2315474024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNSON HEALTHCARE CHARLEVOIX HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207RX0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 367500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | CA | 01 | MI | JVHL | OTHER | 1001019 | 01 | MI | NORTHERN HEALTH PLAN | OTHER | 134141100 | 01 | MI | COMP CARRIER US POSTAL SV | OTHER | 700A560010 | 01 | MI | BCN PROFESSINAL MULTI GRP | OTHER | 20139 | 01 | MI | PRIORITY HEALTH PROFESSIO | OTHER | CD9821 | 01 | MEDICARE RAILROAD GROUP | OTHER | 700A560010 | 01 | MI | BCBS MULTI GROUP | OTHER |