Basic Information
| Provider Information | |||||||||
| NPI: | 1609803717 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IONIA COUNTY MEMORIAL HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ICMH HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165231400 | ||||||||
| FaxNumber: | 6165275731 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488461836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165277060 | ||||||||
| FaxNumber: | 6165275731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROESER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6165274200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 153173015 | 05 | MI | MEDICAID | 0E111 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |