Provider Demographics
NPI:1902149818
Name:BRONSON SOUTH HAVEN HOSPITAL
Entity Type:Organization
Organization Name:BRONSON SOUTH HAVEN HOSPITAL
Other - Org Name:BRONSON URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6000
Mailing Address - Street 1:301 JOHN ST # 42
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5295
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:
Practice Address - Street 1:970 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090
Practice Address - Country:US
Practice Address - Phone:269-637-2916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONSON SOUTH HAVEN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-28
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 363A00000X, 363LF0000X
MI1060000042261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5171922Medicaid