Basic Information
| Provider Information | |||||||||
| NPI: | 1740424068 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRONSON LAKEVIEW HOSPITAL | ||||||||
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| OtherOrganizationName: | BRONSON LAKEVIEW HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 HAZEN ST | ||||||||
| Address2: | |||||||||
| City: | PAW PAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490791019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696573141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | BOX 42 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417806 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2009 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | EAST | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 2693416000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRONSON LAKEVIEW HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0H06012 | 01 | MI | BCBSM | OTHER |