Healthcare Provider Details

I. General information

NPI: 1629494133
Provider Name (Legal Business Name): PENNOCK HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 COOK RD
HASTINGS MI
49058-9616
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 269-945-9520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DEIDRE WELLER
Title or Position: CONTROLLER
Credential:
Phone: 269-945-1212