Provider Demographics
NPI:1003837741
Name:COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:CHEBOYGAN MEMORIAL HOSPITAL HOSPITALIST GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT/FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:P
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-627-1203
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-0419
Mailing Address - Country:US
Mailing Address - Phone:231-627-1438
Mailing Address - Fax:231-627-1471
Practice Address - Street 1:748 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2220
Practice Address - Country:US
Practice Address - Phone:231-627-5601
Practice Address - Fax:231-627-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI160020207Q00000X, 207R00000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0A66000Medicare ID - Type Unspecified