Healthcare Provider Details

I. General information

NPI: 1508924770
Provider Name (Legal Business Name): LAKELAND COMMUNITY HOSPITAL WATERVLIET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MEDICAL PARK DR
WATERVLIET MI
49098-9225
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 269-463-2448
  • Fax: 269-463-5351
Mailing address:
  • Phone: 616-486-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency 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: 616-391-0780