Basic Information
| Provider Information | |||||||||
| NPI: | 1417044660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EATON RAPIDS MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EATON RAPIDS COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EATON RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488271952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176632671 | ||||||||
| FaxNumber: | 5176632472 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EATON RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488271952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176632671 | ||||||||
| FaxNumber: | 5176632472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2006 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5176639474 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 230010 | MI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 00197 | 01 | MI | BLUE CROSS | OTHER | OB37608 | 01 | MI | MEDICARE PTAN | OTHER | OB37608 | 01 | MI | BCBS GROUP PIN | OTHER | 5170569 | 05 | MI | MEDICAID |