Basic Information
| Provider Information | |||||||||
| NPI: | 1811933153 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROMEDICA COLDWATER REGIONAL HOSPITAL-HOME HEALTH & HOSPICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PROMEDICA HOSPICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 274 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490362041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490361688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795420 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEGROOT | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5172795400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 120010 | MI | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 4123831 | 05 | MI | MEDICAID | 7230031 | 01 | MI | PHP/IBA PROVIDER # | OTHER | 08782 | 01 | MI | BCBSM PROVIDER # | OTHER |