Provider Demographics
NPI:1750302493
Name:COMMUNITY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HOSPITAL
Other - Org Name:UC
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT/FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-627-1203
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-0419
Mailing Address - Country:US
Mailing Address - Phone:231-627-1438
Mailing Address - Fax:231-627-1471
Practice Address - Street 1:740 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-2220
Practice Address - Country:US
Practice Address - Phone:231-627-5601
Practice Address - Fax:231-627-1846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207PE0004X
MI261QR1300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI010A660000OtherGROUP BLUE CROSS
238584Medicare ID - Type UnspecifiedRURAL HEALTH
MI010A660000OtherGROUP BLUE CROSS