Provider Demographics
NPI:1790962157
Name:MADISON COMMUNITY HOSPITAL INC
Entity Type:Organization
Organization Name:MADISON COMMUNITY HOSPITAL INC
Other - Org Name:THE BEHAVIORAL CENTER OF MICHIGAN HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECT ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNABALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-261-2266
Mailing Address - Street 1:4050 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2534
Mailing Address - Country:US
Mailing Address - Phone:586-261-2266
Mailing Address - Fax:586-582-9570
Practice Address - Street 1:4050 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2534
Practice Address - Country:US
Practice Address - Phone:586-261-2266
Practice Address - Fax:586-582-9570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010087863336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2043619OtherPK