Provider Demographics
NPI:1104850221
Name:BRONSON METHODIST HOSPITAL
Entity Type:Organization
Organization Name:BRONSON METHODIST HOSPITAL
Other - Org Name:BRONSON METHODIST HOSPITAL DME-HOSPITAL DEPARTMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:SVP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6000
Mailing Address - Street 1:301 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5295
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8913
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-7654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONSON METHODIST HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-11
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390020332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI50-30001OtherUNITED HEALTHCARE
MI5170246Medicaid
MI875170246Medicaid
MI540C912080OtherBCBSM
MI0906440002Medicare Oscar/Certification
MI875170246Medicaid
MI5170246Medicaid