Healthcare Provider Details

I. General information

NPI: 1639196199
Provider Name (Legal Business Name): COMMUNITY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6135 CRESSY ST
INDIAN RIVER MI
49749
US

IV. Provider business mailing address

PO BOX 419
CHEBOYGAN MI
49721-0419
US

V. Phone/Fax

Practice location:
  • Phone: 231-238-8908
  • Fax: 231-238-4419
Mailing address:
  • Phone: 231-627-1438
  • Fax: 231-627-1471

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 StateMI

VIII. Authorized Official

Name: MRS. HOLLY CAMPA
Title or Position: VICE PRESIDENT/FINANCE
Credential:
Phone: 231-627-1203