Basic Information
| Provider Information | |||||||||
| NPI: | 1831443761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MCKENZIE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCKENZIE PROFESSIONAL PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 N DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484711009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106486162 | ||||||||
| FaxNumber: | 8106485058 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | SANDUSKY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484711009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106486162 | ||||||||
| FaxNumber: | 8106485058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUEDISUELI | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | V.P. OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8106486162 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCKENZIE MEMORIAL HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.