Basic Information
| Provider Information | |||||||||
| NPI: | 1700994845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKELAND COMMUNITY HOSPITAL WATERVLIET | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WATERVLIET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490989225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699838300 | ||||||||
| FaxNumber: | 2699824855 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MEDICAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | WATERVLIET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490989225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699838300 | ||||||||
| FaxNumber: | 2699824855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | KONOPACKI | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2693137188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKELAND REGIONAL HEALTH SYSTEM | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 40 5170415 | 05 | MI | MEDICAID | 00184 | 01 | MI | BCBSM | OTHER | 30 1556886 | 05 | MI | MEDICAID |