Basic Information
Provider Information | |||||||||
NPI: | 1477833234 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAGINAW COOPERATIVE HOSPITALS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CMU MEDICAL EDUCATION PARTNERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 HOUGHTON AVE | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486025303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897467500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1000 HOUGHTON AVE | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486025303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897467500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2011 | ||||||||
LastUpdateDate: | 12/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRYCE | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 9897467696 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/18/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 1477833234 | 05 | MI |   | MEDICAID |