Provider Demographics
NPI:1437383296
Name:EATON RAPIDS MEDICAL CENTER
Entity Type:Organization
Organization Name:EATON RAPIDS MEDICAL CENTER
Other - Org Name:EATON RAPIDS MEDICAL CENTER FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:517-663-9474
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-1952
Mailing Address - Country:US
Mailing Address - Phone:517-999-4500
Mailing Address - Fax:517-999-4510
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1952
Practice Address - Country:US
Practice Address - Phone:517-999-4500
Practice Address - Fax:517-999-4510
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EATON RAPIDS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-08
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MI230010261QR1300X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5170569Medicaid
MIOB37608OtherMEDICARE PTAN
MI238633Medicare Oscar/Certification
MI5170569Medicaid