Provider Demographics
NPI:1043562762
Name:MUNISING MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MUNISING MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-387-4110
Mailing Address - Street 1:1500 SANDPOINT RD
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862-1406
Mailing Address - Country:US
Mailing Address - Phone:906-387-4338
Mailing Address - Fax:906-387-2825
Practice Address - Street 1:1500 SANDPOINT RD
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862-1406
Practice Address - Country:US
Practice Address - Phone:906-387-4110
Practice Address - Fax:906-387-2825
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNISING MEMORIAL HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-04
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704294505207Q00000X
MI4301068824207Q00000X
MI4301050177207Q00000X
MI4301076662207Q00000X
MI4301095227207Q00000X
MI4301034044207X00000X
MI1060000115261QR1300X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043562762OtherMEDICAID RHC NPI
MI23-8650OtherRHC CERTIFICATION NUMBER (CMS)
MIOM40920Medicare UPIN