Provider Demographics
NPI:1770597494
Name:BRONSON VICKSBURG HOSPITAL, INC.
Entity type:Organization
Organization Name:BRONSON VICKSBURG HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACT CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-7806
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:13326 N BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MI
Practice Address - Zip Code:49097-1514
Practice Address - Country:US
Practice Address - Phone:269-649-2321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONSON VICKSBURG HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC20578OtherRAILROAD MEDICARE
MI0C96065OtherBCBSM
MI0C96065Medicare PIN