Provider Demographics
NPI:1447258454
Name:MADISON COMMUNITY HOSPITAL INC.
Entity type:Organization
Organization Name:MADISON COMMUNITY HOSPITAL INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNABALAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-583-8922
Mailing Address - Street 1:30781 STEPHENSON HWY
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1618
Mailing Address - Country:US
Mailing Address - Phone:248-583-8922
Mailing Address - Fax:248-583-8969
Practice Address - Street 1:960 RIVER CENTRE DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4463
Practice Address - Country:US
Practice Address - Phone:810-966-8523
Practice Address - Fax:810-966-5056
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON COMMUNITY HOSPITAL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-13
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N99120Medicare ID - Type Unspecified