Basic Information
| Provider Information | |||||||||
| NPI: | 1932695525 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNOCK HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPECTRUM HEALTH PENNOCK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166439143 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1009 W GREEN ST | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490581710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699453451 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2018 | ||||||||
| LastUpdateDate: | 07/06/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEWIS-BLAKE | ||||||||
| AuthorizedOfficialFirstName: | SHERYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT PENNOCK | ||||||||
| AuthorizedOfficialTelephone: | 2699483123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 1060000022 | MI | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 00101 | 01 | BLUE CROSS BLUE SHIELD | OTHER |