Basic Information
| Provider Information | |||||||||
| NPI: | 1710993357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRONSON METHODIST HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRONSON HOME HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | BOX 42 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417806 | ||||||||
| FaxNumber: | 2693418143 | ||||||||
| Practice Location | |||||||||
| Address1: | 6938 ELM VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490097447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417272 | ||||||||
| FaxNumber: | 2693416867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 07/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | FALAHEE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP LEGAL AFFAIRS, C | ||||||||
| AuthorizedOfficialTelephone: | 2693416000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRONSON METHODIST HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 390020 | MI | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 72-30018 | 01 | MI | UNITED HEALTHCARE | OTHER | OE121 | 01 | MI | BCBSM | OTHER | 5246442 | 05 | MI | MEDICAID | 3209753 | 05 | MI | MEDICAID |