Basic Information
| Provider Information | |||||||||
| NPI: | 1497750608 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCKENZIE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MCKENZIE HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 N DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484711009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106486162 | ||||||||
| FaxNumber: | 8106485058 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484711009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106486162 | ||||||||
| FaxNumber: | 8106485058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUEDISUELI | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | V.P. FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8106486162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1060000096 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 275N00000X | MI06100 | MI | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NC0060X | 760030 | MI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 405171190 | 05 | MI | MEDICAID | 301555717 | 05 | MI | MEDICAID |