Basic Information
| Provider Information | |||||||||
| NPI: | 1598909426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECTRUM HEATLH KELSEY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KELSEY MEMORIAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 418 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | LAKEVIEW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488509806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893527211 | ||||||||
| FaxNumber: | 6167542735 | ||||||||
| Practice Location | |||||||||
| Address1: | 418 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | LAKEVIEW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488509806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893527211 | ||||||||
| FaxNumber: | 6167542735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2009 | ||||||||
| LastUpdateDate: | 02/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6162256310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 490051 | MI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 5170961 | 05 | MI | MEDICAID |