Provider Demographics
NPI:1649457771
Name:MUNSON HEALTHCARE MANISTEE HOSPITAL
Entity type:Organization
Organization Name:MUNSON HEALTHCARE MANISTEE HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:O
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-6512
Mailing Address - Street 1:375 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2729
Mailing Address - Country:US
Mailing Address - Phone:231-398-1950
Mailing Address - Fax:
Practice Address - Street 1:1465 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9709
Practice Address - Country:US
Practice Address - Phone:231-398-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST SHORE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-31
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P54180Medicare PIN