Healthcare Provider Details

I. General information

NPI: 1558432237
Provider Name (Legal Business Name): MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 W KING ST SUITE N
OWOSSO MI
48867-2100
US

IV. Provider business mailing address

826 W KING ST PO BOX 456
OWOSSO MI
48867-2120
US

V. Phone/Fax

Practice location:
  • Phone: 989-729-4041
  • Fax:
Mailing address:
  • Phone: 989-729-6353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301041531
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003225
License Number StateMI

VIII. Authorized Official

Name: MIKE GRISDELA
Title or Position: CFO
Credential:
Phone: 989-723-5211