Provider Demographics
NPI:1518186295
Name:PENNOCK HOSPITAL
Entity Type:Organization
Organization Name:PENNOCK HOSPITAL
Other - Org Name:COREWELL HEALTH PENNOCK HOSPITAL PROFESSIONAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, PROVIDER SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CATIGNANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-0008
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 1:1009 W GREEN ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1710
Practice Address - Country:US
Practice Address - Phone:269-945-3451
Practice Address - Fax:269-948-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 363L00000X, 363LF0000X
MIMI4704181864363LF0000X
MIMI5101016321207Q00000X
MIMI4301037024207Q00000X
MIMI5101017259207Q00000X
MIMI4704208860363LF0000X
MIMI4704280658363LF0000X
MIMI4301032332207Q00000X
MI5601006236208M00000X
MI5601006321208M00000X
MI5601003890208M00000X
MI4301061517208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M28750Medicare PIN