Provider Demographics
NPI:1750500435
Name:PENNOCK HOSPITAL
Entity Type:Organization
Organization Name:PENNOCK HOSPITAL
Other - Org Name:SPECIALIST GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-945-1220
Mailing Address - Street 1:1009 W GREEN STREET
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1710
Mailing Address - Country:US
Mailing Address - Phone:269-945-1212
Mailing Address - Fax:269-948-3117
Practice Address - Street 1:1009 W GREEN STREET
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1710
Practice Address - Country:US
Practice Address - Phone:269-945-1212
Practice Address - Fax:269-948-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI43051816207R00000X
MIMI43039857207R00000X
MIMI43075340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA9744OtherMCR RR
MICA9744OtherMCR RR