Great Lakes Specialty Hosptial - Hackley LLC

Primary specialty

Long Term Care HospitalTaxonomy code 282E00000X

License

610057 Issued in MI

Legal business name

GREAT LAKES SPECIALTY HOSPTIAL - HACKLEY LLC

Practice address

1700 Clinton St
2 South, 2ND and 3Rd Floors
Muskegon, MI 49442-5502

Phone

(231) 728-5803

Fax

(231) 728-5820

NPI assigned

Jul 28, 2005

Organization subpart

No

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

Authorized official

Name

Mr. Michael E. Tarvin

Title

Vice President

Phone

(717) 972-1100

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Select Specialty Hospital - Muskegon Doing business as

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Hospital certification: CCN 232021

Legal name

SELECT SPECIALTY HOSPITAL - MUSKEGON

Certification status

Terminated Voluntary: merger or closure, Oct 16, 2020

Provider type (POS)

Hospital – Long-term

Participating since

Jul 1, 1997

Last certification

Apr 2, 2009

Beds

31

Ownership / control type

Private (for profit)

Most recent change of ownership

Sep 1, 2009 (2 total)

Facility address

1700 Clinton Street, 2 South and 3 South Floors
Muskegon, MI 49442

Hospital certification: CCN 233030

Legal name

INTENSIVA HOSPITAL OF MUSKEGON

Certification status

Terminated Other: provider status change, Jul 1, 1997

Provider type (POS)

Hospital – Rehabilitation

Participating since

Dec 3, 1996

Last certification

Dec 3, 1996

Beds

31

Ownership / control type

Private (for profit)

Facility address

1700 Clinton St
Muskegon, MI 49442

Locations

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

{
    "created_epoch": "1122508800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1443484800000",
    "number": "1245230671",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4714 GETTYSBURG RD",
            "address_2": "LEGAL DEPT.",
            "city": "MECHANICSBURG",
            "state": "PA",
            "postal_code": "170554325",
            "telephone_number": "717-972-1100",
            "fax_number": "717-975-9981"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1700 CLINTON ST",
            "address_2": "2 SOUTH, 2ND AND 3RD FLOORS",
            "city": "MUSKEGON",
            "state": "MI",
            "postal_code": "494425502",
            "telephone_number": "231-728-5803",
            "fax_number": "231-728-5820"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES SPECIALTY HOSPTIAL - HACKLEY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-07-28",
        "last_updated": "2015-09-29",
        "status": "A",
        "authorized_official_last_name": "TARVIN",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "717-972-1100",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "282E00000X",
            "taxonomy_group": "",
            "desc": "Long Term Care Hospital",
            "state": "MI",
            "license": "610057",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS MI",
            "identifier": "00347",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Select Specialty Hospital - Muskegon",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Long Term Care Hospital in Muskegon, MI
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• Long Term Care Hospital in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 29, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.