Healthcare Provider Details

I. General information

NPI: 1538328364
Provider Name (Legal Business Name): MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 BOURN ST
LEWISTON MI
49756
US

IV. Provider business mailing address

829 N CENTER AVE
GAYLORD MI
49735-1595
US

V. Phone/Fax

Practice location:
  • Phone: 989-786-4877
  • Fax: 989-786-2187
Mailing address:
  • Phone: 989-731-7777
  • Fax: 989-731-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number690020
License Number StateMI

VIII. Authorized Official

Name: MR. THOMAS R. LEMON
Title or Position: CEO
Credential:
Phone: 989-731-2230