Basic Information
| Provider Information | |||||||||
| NPI: | 1629172275 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARQUETTE GENERAL HOSPITAL, INC. | ||||||||
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| OtherOrganizationName: | MARQUETTE GENERAL HOSPITAL GENERAL SURGICAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4602 DEPARTMENT | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601220021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062254821 | ||||||||
| FaxNumber: | 9062254537 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 W COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498552705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062257430 | ||||||||
| FaxNumber: | 9062254815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 04/21/2009 | ||||||||
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| AuthorizedOfficialLastName: | MULLER | ||||||||
| AuthorizedOfficialFirstName: | A. GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9062254821 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 4301043677 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | 4301088772 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0E21079 | 01 | MI | BLUE CROSS BLUE SHIELD GR | OTHER | CA7435 | 01 | MI | RAILROAD MEDICARE | OTHER |