Provider Demographics
NPI:1588810709
Name:EATON RAPIDS MEDICAL CENTER
Entity type:Organization
Organization Name:EATON RAPIDS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:517-663-9474
Mailing Address - Street 1:400 E MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SPRINGPORT
Mailing Address - State:MI
Mailing Address - Zip Code:49284-9774
Mailing Address - Country:US
Mailing Address - Phone:517-857-4500
Mailing Address - Fax:517-857-4510
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1952
Practice Address - Country:US
Practice Address - Phone:517-857-4500
Practice Address - Fax:517-857-4510
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EATON RAPIDS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-08
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230010261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5170569Medicaid
MIOB37608OtherMEDICARE PTAN
MI5170569Medicaid
MI231324Medicare PIN