Provider Demographics
NPI:1053661231
Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Other - Org Name:MUNSON HEALTHCARE OMH MEDICAL GROUP-INDIAN RIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-731-2230
Mailing Address - Street 1:271 MCCOY RD W
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-8253
Mailing Address - Country:US
Mailing Address - Phone:989-731-7777
Mailing Address - Fax:989-731-7776
Practice Address - Street 1:3860 S STRAITS HWY
Practice Address - Street 2:
Practice Address - City:INDIAN RIVER
Practice Address - State:MI
Practice Address - Zip Code:49749
Practice Address - Country:US
Practice Address - Phone:231-238-0581
Practice Address - Fax:231-238-0856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF96004Medicare PIN