Basic Information
| Provider Information | |||||||||
| NPI: | 1992726632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WCHS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 419 | ||||||||
| Address2: | |||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497210419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316271438 | ||||||||
| FaxNumber: | 2316271471 | ||||||||
| Practice Location | |||||||||
| Address1: | 722 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHEBOYGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497212220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316271493 | ||||||||
| FaxNumber: | 2316271492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 12/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | CAMPA | ||||||||
| AuthorizedOfficialFirstName: | HOLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2316271203 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QR1300X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 700A610040 | 01 | MI | GROUP BLUE CROSS | OTHER |