Basic Information
Provider Information | |||||||||
NPI: | 1811030646 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAGINAW COOPERATIVE HOSPITALS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CMU MEDICAL EDUCATION PARTNERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 HOUGHTON AVE | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486025303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9895836800 | ||||||||
FaxNumber: | 9895836915 | ||||||||
Practice Location | |||||||||
Address1: | 1000 HOUGHTON AVE | ||||||||
Address2: |   | ||||||||
City: | SAGINAW | ||||||||
State: | MI | ||||||||
PostalCode: | 486025303 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9895836800 | ||||||||
FaxNumber: | 9895836915 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2007 | ||||||||
LastUpdateDate: | 07/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GRONDA | ||||||||
AuthorizedOfficialFirstName: | KELLY | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 9895837415 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207RE0101X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207RI0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207V00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 207R00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.