Basic Information
Provider Information | |||||||||
NPI: | 1922488436 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHARLEVOIX AREA HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHARLEVOIX AREA HOSPITAL MIDLEVEL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14700 LAKE SHORE DR | ||||||||
Address2: |   | ||||||||
City: | CHARLEVOIX | ||||||||
State: | MI | ||||||||
PostalCode: | 497201931 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2315474024 | ||||||||
FaxNumber: | 2315478088 | ||||||||
Practice Location | |||||||||
Address1: | 14700 LAKE SHORE DR | ||||||||
Address2: |   | ||||||||
City: | CHARLEVOIX | ||||||||
State: | MI | ||||||||
PostalCode: | 497201931 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2315474024 | ||||||||
FaxNumber: | 2315478088 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2015 | ||||||||
LastUpdateDate: | 06/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILHELM | ||||||||
AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2315478511 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363A00000X |   | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.