Basic Information
| Provider Information | |||||||||
| NPI: | 1578748828 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MGH FAMILY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MUSKEGON FAMILY CARE FAMILY PLANNING SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 OAK AVE | ||||||||
| Address2: | SUITE 011 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494422407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317679806 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1836 OAK AVE | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494422408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317733828 | ||||||||
| FaxNumber: | 2317378262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2008 | ||||||||
| LastUpdateDate: | 01/07/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LITTLEJOHN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2317334800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MGH FAMILY HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M. ED. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0050X | Y | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0M32670 | 01 | MI | MEDICARE PTAN | OTHER |