Provider Demographics
NPI:1558544106
Name:BRONSON VICKSBURG HOSPITAL
Entity Type:Organization
Organization Name:BRONSON VICKSBURG HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-7654
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-649-9136
Mailing Address - Fax:
Practice Address - Street 1:13326 N BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-1514
Practice Address - Country:US
Practice Address - Phone:269-649-9136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONSON VICKSBURG HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0696065Medicare PIN