Basic Information
| Provider Information | |||||||||
| NPI: | 1508225632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENNOCK HOSPITAL BOARD OF TRUSTEES | ||||||||
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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: | 1108 W STATE ST | ||||||||
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| City: | HASTINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490589711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699458080 | ||||||||
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| ProviderEnumerationDate: | 02/17/2016 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP PHYSICIAN NETWORK | ||||||||
| AuthorizedOfficialTelephone: | 2699451220 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENNOCK HOSPITAL BOARD OF TRUSTEES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.