Provider Demographics
NPI:1407949191
Name:MUNSON HEALTHCARE MANISTEE HOSPITAL
Entity Type:Organization
Organization Name:MUNSON HEALTHCARE MANISTEE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AMBULATORY CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-7840
Mailing Address - Street 1:1465 E PARKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9785
Mailing Address - Country:US
Mailing Address - Phone:231-398-1000
Mailing Address - Fax:231-398-0364
Practice Address - Street 1:1465 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9785
Practice Address - Country:US
Practice Address - Phone:231-398-1000
Practice Address - Fax:231-398-0364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X, 207L00000X, 207P00000X, 367500000X
MI275N00000X
MI510020282N00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No275N00000XHospital UnitsMedicare Defined Swing Bed UnitGroup - Single Specialty
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4971251Medicaid
MI00198OtherBLUE CROSS
MI1556474Medicaid
MI5172278Medicaid
MI00198OtherBLUE CROSS
MI1556474Medicaid
MI230303Medicare PIN
MIE16256Medicare PIN