Basic Information
| Provider Information | |||||||||
| NPI: | 1871672618 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLLAND COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HOLLAND HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494234918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163925141 | ||||||||
| FaxNumber: | 6163943729 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494234918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163925141 | ||||||||
| FaxNumber: | 6163943729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROEHLING | ||||||||
| AuthorizedOfficialFirstName: | ALEX | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6163925141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 251E00000X | N | Agencies | Home Health | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00130 | 01 | MI | BCBSM | OTHER | 30 1898523 | 05 | MI | MEDICAID | P00130 | 01 | MI | BCN | OTHER | 650 | 01 | MI | PRIORITY HEALTH | OTHER | 40 1898541 | 05 | MI | MEDICAID |