Provider Demographics
NPI:1083658140
Name:COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:CHEBOYGAN MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-627-7111
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:231-627-5601
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:2006-06-16
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI160020282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00141OtherBLUE CROSS
MI1557767Medicaid
MI5170424Medicaid
MI5170424Medicaid