Basic Information
| Provider Information | |||||||||
| NPI: | 1245230671 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES SPECIALTY HOSPTIAL - HACKLEY LLC | ||||||||
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| OtherOrganizationName: | SELECT SPECIALTY HOSPITAL - MUSKEGON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4714 GETTYSBURG RD | ||||||||
| Address2: | LEGAL DEPT. | ||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170554325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179721100 | ||||||||
| FaxNumber: | 7179759981 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 CLINTON ST | ||||||||
| Address2: | 2 SOUTH, 2ND AND 3RD FLOORS | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317285803 | ||||||||
| FaxNumber: | 2317285820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2005 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | TARVIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7179721100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 610057 | MI | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00347 | 01 | MI | BCBS MI | OTHER |