Provider Demographics
NPI:1164540555
Name:DECKERVILLE COMMUNITY HOSPITAL, INC.
Entity Type:Organization
Organization Name:DECKERVILLE COMMUNITY HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-376-2835
Mailing Address - Street 1:3559 PINE STREET
Mailing Address - Street 2:
Mailing Address - City:DECKERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48427
Mailing Address - Country:US
Mailing Address - Phone:810-376-2835
Mailing Address - Fax:810-376-9412
Practice Address - Street 1:3559 PINE STREET
Practice Address - Street 2:
Practice Address - City:DECKERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48427
Practice Address - Country:US
Practice Address - Phone:810-376-2835
Practice Address - Fax:810-376-9412
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DECKERVILLE COMMUNITY HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-26
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG61003OtherBCBSM
MI138358OtherGREAT LAKES HEALTH PLAN
MI138358OtherGREAT LAKES HEALTH PLAN