Provider Demographics
NPI:1124028972
Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Other - Org Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAITLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-7840
Mailing Address - Street 1:825 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1592
Mailing Address - Country:US
Mailing Address - Phone:989-731-2100
Mailing Address - Fax:989-731-2205
Practice Address - Street 1:825 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735
Practice Address - Country:US
Practice Address - Phone:989-731-2100
Practice Address - Fax:989-731-2205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5171593Medicaid
MI00027OtherBCBS OF MI
MI1557589Medicaid
MI00027OtherBCBS OF MI
MI0M10800Medicare UPIN
MI230133Medicare PIN
MI0M72150Medicare PIN
MI5171593Medicaid