NPIMap

Organization Active NPI

Pennock Hospital

Doing business as Corewell Health Pennock Hospital Family Medicine - Middleville

  • Rural Health Clinic/Center
  • Middleville, MI
National Provider Identifier
1013453760
Registry record updated Aug 23, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PENNOCK HOSPITAL
Doing business as
Corewell Health Pennock Hospital Family Medicine - Middleville
Spectrum Health Pennock Family Medicine - Middleville
Practice address
490 Edward St
Middleville, MI 49333-9131
Phone
(269) 795-4434
Fax
(269) 795-4271
NPI assigned
Jan 18, 2017
Last updated
Aug 23, 2023By the provider in NPPES
Organization subpart
Yes
Parent organization
PENNOCK HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 23, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John Sella
Title
Controller
Phone
(616) 802-0206

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

490 Edward St
Middleville, MI 49333-9131

Mailing address

100 Michigan St NE
MC 845
Grand Rapids, MI 49503-2560

Other names 2

  • Corewell Health Pennock Hospital Family Medicine - Middleville Doing business as
  • Spectrum Health Pennock Family Medicine - Middleville Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180920002249 MI Part A Provider - Rural Health Clinic 4587551015 Practice locations: Middleville, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013453760. Details of each certification follow.

Rural health clinic certification: CCN 238703

Legal name
PENNOCK HOSPITAL
Doing business as
COREWELL HEALTH PENNOCK HOSPITAL FAMILY MEDICINE-MIDDLEVILLE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 2, 2017
Last certification
Jul 31, 2025
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
490 Edward St
Middleville, MI 49333-9131
Related CCNs
231339

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

  • Pennock Hospital

    dba Corewell Health Pennock Hospital Family Medicine - State St

    • Rural Health Clinic/Center
    • Hastings, MI
    • NPI 1396190138

    4587551015

    Same PAC ID
  • Pennock Hospital

    dba Corewell Health Pennock Hospital Professional

    • Family Medicine Physician
    • Hastings, MI
    • NPI 1518186295

    4587551015

    Same PAC ID
  • Pennock Hospital

    dba Corewell Health Pennock Hospital Family Medicine - Gun Lake

    • Rural Health Clinic/Center
    • Wayland, MI
    • NPI 1801250907

    4587551015

    Same PAC ID
  • Pennock Hospital

    dba Corewell Health Pennock Hospital Multispecialty Center - Green St

    • Rural Health Clinic/Center
    • Hastings, MI
    • NPI 1841644184

    4587551015

    Same PAC ID
  • Pennock Hospital

    dba Corewell Health Pennock Hospital

    • Critical Access Hospital
    • Hastings, MI
    • NPI 1932695525

    4587551015

    Same PAC ID
  • Pennock Hospital

    dba Corewell Health Pennock Hospital Family Medicine - Lake Odessa

    • Rural Health Clinic/Center
    • Lake Odessa, MI
    • NPI 1962889584

    4587551015

    Same PAC ID

National Provider Directory

National Provider Directory
Part of
Deborah a Joseph DO

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Christina Freese Decker Individual Corporate Director Aug 18, 2020
Talawnda L Bragg Individual Corporate Director Jan 1, 2022
Christopher B Port Individual Corporate Director Aug 18, 2020
Ronald M Hofman Individual Corporate Director Aug 18, 2020
Annica Euurand Waalkes Individual Corporate Director Aug 18, 2020
Teresa Arlene Treiber Individual W-2 Managing Employee Nov 1, 2025
Matthew E Cox Individual Corporate OfficerSVP Chief Finance Officer Feb 1, 2022
Operational/Managerial Control Feb 1, 2022
Mark Wilson Individual Corporate Director Aug 18, 2020
Corewell Health Organization, Grand Rapids, MI Corporation, Non-profit, Chain home office Operational/Managerial Control May 1, 2015
Johannie M Torres Individual Corporate Director Aug 18, 2020
Mary Doornbos Individual Corporate Director Aug 18, 2020
John Buckley Individual Corporate Director Aug 18, 2020
Sam R Watson Individual Corporate Director Oct 1, 2012
Bill P Pink Individual Corporate Director Aug 18, 2020
Simin Beg Individual Corporate Director Aug 18, 2020
Lynnette Ferrell-Robinson Individual Corporate Director Aug 18, 2020
Tamila Marlow Individual W-2 Managing Employee Nov 1, 2025

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 66

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 66

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1484697600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692748800000",
    "number": "1013453760",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 MICHIGAN ST NE",
            "address_2": "MC 845",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495032560"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "490 EDWARD ST",
            "city": "MIDDLEVILLE",
            "state": "MI",
            "postal_code": "493339131",
            "telephone_number": "269-795-4434",
            "fax_number": "269-795-4271"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENNOCK HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PENNOCK HOSPITAL",
        "enumeration_date": "2017-01-18",
        "last_updated": "2023-08-23",
        "certification_date": "2023-08-23",
        "status": "A",
        "authorized_official_last_name": "SELLA",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "CONTROLLER",
        "authorized_official_telephone_number": "616-802-0206"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Corewell Health Pennock Hospital Family Medicine - Middleville",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Spectrum Health Pennock Family Medicine - Middleville",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Middleville, MI

Sources for this page

Verify at the official NPI Registry.