Basic Information
| Provider Information | |||||||||
| NPI: | 1790962157 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISON COMMUNITY HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | THE BEHAVIORAL CENTER OF MICHIGAN HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4050 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862612266 | ||||||||
| FaxNumber: | 5865829570 | ||||||||
| Practice Location | |||||||||
| Address1: | 4050 E 12 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480922534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862612266 | ||||||||
| FaxNumber: | 5865829570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 07/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | GUNABALAN | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECT ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 5862612266 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | 5301008786 | MI | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2043619 | 01 | PK | OTHER |