Provider Demographics
NPI:1376657239
Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Other - Org Name:OTSEGO EMERGENCY PHYSICIANS
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-731-2100
Mailing Address - Street 1:825 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1592
Mailing Address - Country:US
Mailing Address - Phone:989-731-2140
Mailing Address - Fax:
Practice Address - Street 1:825 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735
Practice Address - Country:US
Practice Address - Phone:989-731-2140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F960010OtherBLUE CROSS OF MICHIGAN
MI700F960010OtherBLUE CROSS OF MICHIGAN