Provider Demographics
NPI:1841488178
Name:PENNOCK HOSPITAL BOARD OF TRUSTEES
Entity type:Organization
Organization Name:PENNOCK HOSPITAL BOARD OF TRUSTEES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SALISBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-945-1212
Mailing Address - Street 1:1009 W GREEN STREET
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1710
Mailing Address - Country:US
Mailing Address - Phone:269-945-1212
Mailing Address - Fax:269-948-3117
Practice Address - Street 1:1009 W GREEN STREET
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1710
Practice Address - Country:US
Practice Address - Phone:269-945-1212
Practice Address - Fax:269-948-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI4301050284207P00000X
MIMI5101007600207P00000X
MIMI5101016002207P00000X
MIMI5101014686207P00000X
MIMI47051642363AM0700X
MIMI56003475363AM0700X
MIMI56004150363AM0700X
MIMI56003622363AM0700X
MIMI5601004651363A00000X
MIMI5601003702363A00000X
MIMI4701051624363L00000X
MIMI5601004976363A00000X
MIMI4301073150207P00000X
MIMI51010795207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1265453005OtherNPI
MI1336185362OtherNPI
MI1245412733OtherNPI
MI1093812182OtherNPI
MI1124125588OtherNPI
MI1922042829OtherNPI
MI1528004637OtherNPI
MI1649216789OtherNPI
MI1649244666OtherNPI
MI1689625121OtherNPI
MI1225069008OtherNPI
MI1669417655OtherNPI
MI1841220027OtherNPI