Provider Demographics
NPI:1508146457
Name:MECOSTA COUNTY MEDICAL CENTER
Entity Type:Organization
Organization Name:MECOSTA COUNTY MEDICAL CENTER
Other - Org Name:COREWELL HEALTH BIG RAPIDS HOSPITAL PROFESSIONAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-796-8691
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:705 OAK ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-3107
Practice Address - Country:US
Practice Address - Phone:231-796-7607
Practice Address - Fax:231-796-7557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MECOSTA COUNTY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-24
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207X00000X
MI208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P39410OtherMEDICARE PTAN