Basic Information
| Provider Information | |||||||||
| NPI: | 1609011923 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IONIA COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FHC-PORTLAND RHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9751 E GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488759774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176476722 | ||||||||
| FaxNumber: | 5176476838 | ||||||||
| Practice Location | |||||||||
| Address1: | 9751 E GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488759774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176476722 | ||||||||
| FaxNumber: | 5176476838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2008 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROESER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6165231400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | IONIA COUNTY MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 340021 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.