Provider Demographics
NPI:1477940773
Name:PENNOCK HOSPITAL
Entity Type:Organization
Organization Name:PENNOCK HOSPITAL
Other - Org Name:COREWELL HEALTH PENNOCK HOSPITAL MULTISPECIALTY CENTER - IONIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-945-1212
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 1:2776 S STATE RD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-8472
Practice Address - Country:US
Practice Address - Phone:616-775-7500
Practice Address - Fax:616-775-7510
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENNOCK HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-24
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238679OtherMEDICARE PTAN