Basic Information
| Provider Information | |||||||||
| NPI: | 1013453760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENNOCK HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPECTRUM HEALTH PENNOCK FAMILY MEDICINE - MIDDLEVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC 845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 490 EDWARD ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493339131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2697954434 | ||||||||
| FaxNumber: | 2697954271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2017 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS-BLAKE | ||||||||
| AuthorizedOfficialFirstName: | SHERYL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2699483123 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENNOCK HOSPITAL | ||||||||
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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.