Provider Demographics
NPI:1790261832
Name:BRONSON SOUTH HAVEN HOSPITAL
Entity Type:Organization
Organization Name:BRONSON SOUTH HAVEN HOSPITAL
Other - Org Name:BRONSON FASTCARE SOUTH HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6000
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7654
Mailing Address - Fax:
Practice Address - Street 1:970 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090
Practice Address - Country:US
Practice Address - Phone:269-639-2916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONSON SOUTH HAVEN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5171922Medicaid