Provider Demographics
NPI:1326124058
Name:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Entity Type:Organization
Organization Name:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Other - Org Name:PHYSICIAN CLINIC OF CHARLEVOIX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-547-4024
Mailing Address - Street 1:14709 W. UPRIGHT STREET
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1949
Mailing Address - Country:US
Mailing Address - Phone:231-547-6519
Mailing Address - Fax:231-547-5404
Practice Address - Street 1:14709 W. UPRIGHT STREET
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1949
Practice Address - Country:US
Practice Address - Phone:231-547-6519
Practice Address - Fax:231-547-5404
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-27
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X, 207R00000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A51041OtherBLUE SHIELD
MI0P60220Medicare PIN
0P60220Medicare PIN