Healthcare Provider Details

I. General information

NPI: 1326495326
Provider Name (Legal Business Name): PENNOCK HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9090 S RODGERS CT SE
CALEDONIA MI
49316-8052
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-891-0422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DEIDRE WELLER
Title or Position: CONTROLLER
Credential:
Phone: 269-948-3122