Basic Information
| Provider Information | |||||||||
| NPI: | 1942593413 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH HAVEN COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SHORELINE WOMEN'S CENTER RHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696375271 | ||||||||
| FaxNumber: | 2696392819 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 S. BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696375271 | ||||||||
| FaxNumber: | 2696392819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2011 | ||||||||
| LastUpdateDate: | 05/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | GROSS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2696375271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.