Basic Information
| Provider Information | |||||||||
| NPI: | 1548205586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROMEDICA COLDWATER REGIONAL HOSPITAL-HOME HEALTH & HOSPICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROMEDICA HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 274 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490362041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795400 | ||||||||
| FaxNumber: | 5172795429 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490361688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795420 | ||||||||
| FaxNumber: | 5172795429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | DEGROOT | ||||||||
| AuthorizedOfficialFirstName: | RANDALL (RANDY) | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5172795489 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 120010 | MI | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0E152 | 01 | MI | BCBSM HH PROVIDER # | OTHER | 7230031 | 01 | MI | PHP/IBA HH PROVIDER # | OTHER | 3440164 | 05 | MI | MEDICAID |