Provider Demographics
NPI:1063535805
Name:HESPERIA MEDICAL CENTER
Entity type:Organization
Organization Name:HESPERIA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:231-854-6415
Mailing Address - Street 1:78 N DIVISION
Mailing Address - Street 2:PO BOX 308
Mailing Address - City:HESPERIA
Mailing Address - State:MI
Mailing Address - Zip Code:49421
Mailing Address - Country:US
Mailing Address - Phone:231-854-6415
Mailing Address - Fax:231-854-6975
Practice Address - Street 1:78 N DIVISION
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:MI
Practice Address - Zip Code:49421
Practice Address - Country:US
Practice Address - Phone:231-854-6415
Practice Address - Fax:231-854-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI009157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID