Provider Demographics
NPI:1215221353
Name:PENNOCK HOSPITAL
Entity Type:Organization
Organization Name:PENNOCK HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:DEIDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-945-1212
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1005 W GREEN ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1712
Practice Address - Country:US
Practice Address - Phone:269-948-8411
Practice Address - Fax:269-948-9874
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENNOCK HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-07
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M285750Medicare PIN