Provider Demographics
NPI:1255664470
Name:GERBER MEMORIAL HEALTH SERVICE
Entity Type:Organization
Organization Name:GERBER MEMORIAL HEALTH SERVICE
Other - Org Name:WOUND CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:231-854-6415
Mailing Address - Street 1:230 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-9006
Mailing Address - Country:US
Mailing Address - Phone:231-834-5995
Mailing Address - Fax:231-834-0248
Practice Address - Street 1:230 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:MI
Practice Address - Zip Code:49327-9006
Practice Address - Country:US
Practice Address - Phone:231-834-5995
Practice Address - Fax:231-834-0248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43028094174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238572Medicare PIN