=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033446828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEE MEMORIAL HOSPITAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2009
-----------------------------------------------------
Last Update Date | 11/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W DIVISION ST
-----------------------------------------------------
City | DOWAGIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49047-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-782-2111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 W HIGH ST
-----------------------------------------------------
City | DOWAGIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49047-1943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-783-3089
-----------------------------------------------------
Fax | 269-783-3097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | KEN HOLST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-783-3034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | SFE1414003186
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------