Basic Information
| Provider Information | |||||||||
| NPI: | 1366474066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARQUETTE GENERAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1414 W FAIR AVE STE 332 | ||||||||
| Address2: | |||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498555407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253922 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1414 W FAIR AVE STE 332 | ||||||||
| Address2: | |||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498555407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253922 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ACHARYA | ||||||||
| AuthorizedOfficialFirstName: | SHEETAL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9062253922 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301086286 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 4781364 | 05 | MI | MEDICAID |