Basic Information
| Provider Information | |||||||||
| NPI: | 1720475023 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENNOCK HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC 845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 551 LINN ST | ||||||||
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| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490101595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699459520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2015 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2699483122 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PENNOCK HOSPITAL | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.