Provider Demographics
NPI:1538328364
Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Other - Org Name:OMH MEDICAL GROUP - LEWISTON
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-731-2230
Mailing Address - Street 1:829 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1595
Mailing Address - Country:US
Mailing Address - Phone:989-731-7777
Mailing Address - Fax:989-731-7776
Practice Address - Street 1:3040 BOURN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:MI
Practice Address - Zip Code:49756
Practice Address - Country:US
Practice Address - Phone:989-786-4877
Practice Address - Fax:989-786-2187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI690020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF96004Medicare PIN