Provider Demographics
NPI:1629154307
Name:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Entity Type:Organization
Organization Name:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Other - Org Name:CHARLEVOIX PHYSICIAN SPECIALISTS, CHARLEVOIX WOMEN'S HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-547-4024
Mailing Address - Street 1:14651 W UPRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1266
Mailing Address - Country:US
Mailing Address - Phone:231-547-4477
Mailing Address - Fax:231-547-4753
Practice Address - Street 1:14651 W. UPRIGHT ST
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1226
Practice Address - Country:US
Practice Address - Phone:231-582-4477
Practice Address - Fax:231-547-4753
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-27
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207V00000X
207Y00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3196127Medicaid
MI0A51002OtherBLUE SHIELD GRP
0P48530Medicare PIN
MI0P48530Medicare PIN
MI0A51002OtherBLUE SHIELD GRP
MI=========OtherPRIORITY HEALTH PROF
MI=========OtherTRICARE PROFESSIONAL