Provider Demographics
NPI:1770599052
Name:BRONSON SOUTH HAVEN HOSPITAL
Entity type:Organization
Organization Name:BRONSON SOUTH HAVEN HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP, CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
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:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-6743
Mailing Address - Country:US
Mailing Address - Phone:269-341-6000
Mailing Address - Fax:269-341-8913
Practice Address - Street 1:520 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1490
Practice Address - Country:US
Practice Address - Phone:269-427-5811
Practice Address - Fax:269-427-6107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 261QM1300X
MI1060000042261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI238533Medicare PIN