Provider Demographics
NPI:1619039682
Name:BORGESS LEE MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:BORGESS LEE MEMORIAL HOSPITAL
Other - Org Name:BORGESS LEE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-783-3080
Mailing Address - Street 1:420 WEST HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-1943
Mailing Address - Country:US
Mailing Address - Phone:269-783-3089
Mailing Address - Fax:269-783-3097
Practice Address - Street 1:117 S BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-1242
Practice Address - Country:US
Practice Address - Phone:269-445-0771
Practice Address - Fax:269-445-0939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISFE1414003186261QR1300X
261QR1300X
MI261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
238578Medicare PIN