Provider Demographics
NPI:1326495326
Name:PENNOCK HOSPITAL
Entity Type:Organization
Organization Name:PENNOCK HOSPITAL
Other - Org Name:SPECTRUM HEALTH PENNOCK
Other - Org Type:Doing Business As
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:269-948-3122
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 1:9090 S RODGERS CT SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8052
Practice Address - Country:US
Practice Address - Phone:616-891-0422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENNOCK HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty