Basic Information
| Provider Information | |||||||||
| NPI: | 1619039682 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BORGESS LEE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BORGESS LEE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 420 WEST HIGH STREET | ||||||||
| Address2: | |||||||||
| City: | DOWAGIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490471943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2697833089 | ||||||||
| FaxNumber: | 2697833097 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 S BROADWAY STREET | ||||||||
| Address2: | |||||||||
| City: | CASSOPOLIS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490311242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694450771 | ||||||||
| FaxNumber: | 2694450939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 04/29/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RYDER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 2697833080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | SFE1414003186 | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261QR1300X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.