Provider Demographics
NPI:1548401284
Name:CHARLEVOIX AREA HOSPITAL
Entity Type:Organization
Organization Name:CHARLEVOIX AREA HOSPITAL
Other - Org Name:CHARLEVOIX SURGEONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-547-8500
Mailing Address - Street 1:14695 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1929
Mailing Address - Country:US
Mailing Address - Phone:231-547-2812
Mailing Address - Fax:231-547-3067
Practice Address - Street 1:14695 PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1929
Practice Address - Country:US
Practice Address - Phone:231-547-2812
Practice Address - Fax:231-547-3067
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLEVOIX AREA HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-10
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083744208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty