Basic Information
Provider Information | |||||||||
NPI: | 1700847977 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARQUETTE GENERAL HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARQUETTE MEDICAL CLINIC IRON RIVER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4602 DEPT | ||||||||
Address2: |   | ||||||||
City: | CAROL STREAM | ||||||||
State: | IL | ||||||||
PostalCode: | 601220021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9062254533 | ||||||||
FaxNumber: | 9062254537 | ||||||||
Practice Location | |||||||||
Address1: | 1500 W ICE LAKE RD | ||||||||
Address2: |   | ||||||||
City: | IRON RIVER | ||||||||
State: | MI | ||||||||
PostalCode: | 499358509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9062655378 | ||||||||
FaxNumber: | 9062656332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2006 | ||||||||
LastUpdateDate: | 04/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MULLER | ||||||||
AuthorizedOfficialFirstName: | A. GARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9062254821 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | RR1029 | 01 | MI | RAILROAD MEDICARE | OTHER | CI0319 | 01 | MI | RAILROAD MEDICARE | OTHER | CA1145 | 01 | MI | RAILROAD MEDICARE | OTHER | 700C61002 | 01 | MI | BCBSM GROUP | OTHER |