Basic Information
Provider Information | |||||||||
NPI: | 1932628922 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MUNISING MEMORIAL HOSPITAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAY CARE MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 SAND POINT RD | ||||||||
Address2: |   | ||||||||
City: | MUNISING | ||||||||
State: | MI | ||||||||
PostalCode: | 49862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9063874338 | ||||||||
FaxNumber: | 9063872825 | ||||||||
Practice Location | |||||||||
Address1: | E21843 GRAND MARAIS AVE | ||||||||
Address2: |   | ||||||||
City: | GRAND MARAIS | ||||||||
State: | MI | ||||||||
PostalCode: | 498394986 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9063874338 | ||||||||
FaxNumber: | 9063872825 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2017 | ||||||||
LastUpdateDate: | 08/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLSWORTH | ||||||||
AuthorizedOfficialFirstName: | HANNAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHYSICIAN SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9063874110 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MUNISING MEMORIAL HOSPITAL ASSOCIATION | ||||||||
AuthorizedOfficialNamePrefix: | MISS | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | BSN, RN | ||||||||
NPICertificationDate: | 08/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.