Provider Demographics
NPI:1336184621
Name:HPCN
Entity Type:Organization
Organization Name:HPCN
Other - Org Name:HACKLEY INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-728-1678
Mailing Address - Street 1:1675 LEAHY ST
Mailing Address - Street 2:SUITE 215A
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5500
Mailing Address - Country:US
Mailing Address - Phone:231-728-1690
Mailing Address - Fax:231-728-1689
Practice Address - Street 1:1675 LEAHY ST
Practice Address - Street 2:SUITE 215A
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5500
Practice Address - Country:US
Practice Address - Phone:231-728-1690
Practice Address - Fax:231-728-1689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N79640Medicare PIN