Provider Demographics
NPI:1083710701
Name:LAKELAND COMMUNITY HOSPITAL WATERVLIET
Entity Type:Organization
Organization Name:LAKELAND COMMUNITY HOSPITAL WATERVLIET
Other - Org Name:COREWELL HEALTH WATERVLIET HOSPITAL PRIMARY CARE - COLOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-391-0780
Mailing Address - Street 1:400 MEDICAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098
Mailing Address - Country:US
Mailing Address - Phone:269-463-2448
Mailing Address - Fax:269-463-5351
Practice Address - Street 1:6701 PAW PAW AVE
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-9519
Practice Address - Country:US
Practice Address - Phone:269-468-6430
Practice Address - Fax:269-468-0013
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COREWELL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-16
Last Update Date:2023-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700A110160OtherBCBSM
MI238603Medicare Oscar/Certification
MI700A110160OtherBCBSM