Basic Information
Provider Information | |||||||||
NPI: | 1639196199 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | IRMC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 419 | ||||||||
Address2: |   | ||||||||
City: | CHEBOYGAN | ||||||||
State: | MI | ||||||||
PostalCode: | 497210419 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2316271438 | ||||||||
FaxNumber: | 2316271471 | ||||||||
Practice Location | |||||||||
Address1: | 6135 CRESSY ST | ||||||||
Address2: |   | ||||||||
City: | INDIAN RIVER | ||||||||
State: | MI | ||||||||
PostalCode: | 49749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2312388908 | ||||||||
FaxNumber: | 2312384419 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2006 | ||||||||
LastUpdateDate: | 12/08/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CAMPA | ||||||||
AuthorizedOfficialFirstName: | HOLLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2316271203 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QR1300X |   | MI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 700A610050 | 01 | MI | GROUP BLUE CROSS | OTHER |