Basic Information
| Provider Information | |||||||||
| NPI: | 1285829168 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARQUETTE GENERAL HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARQUETTE GENERAL UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4602 DEPT | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601220021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062254821 | ||||||||
| FaxNumber: | 9062254537 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 W FAIR AVE | ||||||||
| Address2: | SUITE 249 | ||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498552675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253893 | ||||||||
| FaxNumber: | 9062254893 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 04/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | MULLER | ||||||||
| AuthorizedOfficialFirstName: | A. GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9062254821 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0E21094 | 01 | MI | BCBSM | OTHER |