Provider Demographics
NPI:1174749170
Name:BRONSON SOUTH HAVEN HOSPITAL
Entity type:Organization
Organization Name:BRONSON SOUTH HAVEN HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP, CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6000
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:269-341-8419
Mailing Address - Fax:269-341-8913
Practice Address - Street 1:950 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8744
Practice Address - Country:US
Practice Address - Phone:269-637-5271
Practice Address - Fax:269-639-2818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 261QU0200X
MI800020282N00000X
MI1060000042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H06003OtherBCBS GROUP NUMBER
MI800020OtherLICENSE NUMBER
MI0H06003Medicare PIN
MI800020OtherLICENSE NUMBER