Provider Demographics
NPI:1609803717
Name:IONIA COUNTY MEMORIAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:IONIA COUNTY MEMORIAL HOSPITAL CORPORATION
Other - Org Name:ICMH HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROESER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-527-4200
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:616-523-1400
Mailing Address - Fax:616-527-5731
Practice Address - Street 1:525 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-1836
Practice Address - Country:US
Practice Address - Phone:616-527-7060
Practice Address - Fax:616-527-5731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI153173015Medicaid
MI0E111OtherBLUE CROSS BLUE SHIELD
MI153173015Medicaid