Provider Demographics
NPI:1760552574
Name:HERRICK MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:HERRICK MEMORIAL HOSPITAL, INC.
Other - Org Name:HERRICK MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HAYLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:STUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7576
Mailing Address - Street 1:502 EAST POTTAWATTAMIE ST.
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-2018
Mailing Address - Country:US
Mailing Address - Phone:517-424-3365
Mailing Address - Fax:517-424-3902
Practice Address - Street 1:502 EAST POTTAWATTAMIE ST.
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-2018
Practice Address - Country:US
Practice Address - Phone:517-424-3365
Practice Address - Fax:517-424-3902
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERRICK MEMORIAL HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-09
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI464010313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI464010Medicaid
235560Medicare Oscar/Certification