MEDICARE: MECOSTA COUNTY MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician		MI

General Provider Information

NPI Number	:	1891075479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECOSTA COUNTY MEDICAL CENTER

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE
Second Line	:	MC845
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:	616-486-6790
Fax Number	:

Provider Business Practice Location Address
First Line	:	722 LOCUST ST
Second Line	:
City	:	BIG RAPIDS
State	:	MI
Zip	:	49307-2040
Country	:	US
Telephone Number	:	231-592-4200
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. THOMAS E DAUGHERTY
Credential	:
Telephone Number	:	231-796-8691

Provider Enumeration Date	:	08/26/2011
Last Update Date	:	05/06/2014

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1891109591 — MECOSTA COUNTY MEDICAL CENTER
Practice Location Address:

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Directions to “MECOSTA COUNTY MEDICAL CENTER ” Practice Location

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