Provider Demographics
NPI:1619935012
Name:MARQUETTE GENERAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:MARQUETTE GENERAL HOSPITAL, INC.
Other - Org Name:PEDIATRIC SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:A. GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-225-3925
Mailing Address - Street 1:4602 DEPT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-4533
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:STE 226
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3925
Practice Address - Fax:906-225-4838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E21011OtherBCBS GROUP
MI=========027OtherTRICARE GROUP