Healthcare Provider Details

I. General information

NPI: 1023114741
Provider Name (Legal Business Name): LAKELAND COMMUNITY HOSPITAL WATERVLIET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/01/2023
Certification Date: 04/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S CENTER ST
HARTFORD MI
49057-1362
US

IV. Provider business mailing address

400 MEDICAL PARK DRIVE
WATERVLIET MI
49098
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-4063
  • Fax: 269-621-9972
Mailing address:
  • Phone: 269-463-2448
  • Fax: 269-463-5351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW COX
Title or Position: CFO
Credential:
Phone: 616-915-3777