=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356718761
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH HAVEN COMMUNITY HEALTH SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 09/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 S BAILEY AVE
-----------------------------------------------------
City | SOUTH HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49090-6743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-637-5271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 S BAILEY AVE
-----------------------------------------------------
City | SOUTH HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49090-6743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HR DIRECTOR
-----------------------------------------------------
Name | KIMBERLY WISE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-637-2801
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 5601007459
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------