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Organization Active NPI

Lakeland Community Hospital Watervliet

  • Rural Health Clinic/Center
  • Watervliet, MI
National Provider Identifier
1508924770
Registry record updated Jan 16, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
LAKELAND COMMUNITY HOSPITAL WATERVLIET
Practice address
400 Medical Park Dr
Watervliet, MI 49098-9225
Phone
(269) 463-2448
Fax
(269) 463-5351
NPI assigned
Dec 4, 2006
Organization subpart
Yes
Parent organization
COREWELL HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 16, 2024

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

Authorized official

Name
Matthew Cox
Title
Cfo
Phone
(616) 391-0780

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Emergency Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207P00000X
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

400 Medical Park Dr
Watervliet, MI 49098-9225

Mailing address

100 Michigan St NE # Mc845
Grand Rapids, MI 49503-2560
Phone (616) 486-6790

Other names 1

  • Corewell Health Watervliet Hospitals Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040416000984 MI Part B Supplier - Clinic/Group Practice 7416942750 Receives reassigned benefits from 128 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Saint Joseph, MI; Watervliet, MI; Niles, MI; Coloma, MI; Berrien Springs, MI; Hartford, MI
O20070119000280 MI Part A Provider - Rural Health Clinic 7416942750 Practice locations: Watervliet, MI

Rural health clinic certification: CCN 238605

Legal name
LAKELAND COMMUNITY HOSPITAL WATERVLIET
Doing business as
COREWELL HEALTH WATERVLIET HOSPITAL PRIMARY CARE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 23, 2007
Last certification
Sep 14, 2020
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
400 Medical Park Dr
Watervliet, MI 49098-9225
Related CCNs
230078

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).

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Corewell Health East

Locations

400 Medical Park Dr
Ste 200
Watervliet, MI 49098
Phone (269) 463-4000

420 Medical Park Dr
Watervliet, MI 49098

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
Kenneth Oneill Individual Corporate Director Jan 1, 2022
Jerry French Individual Corporate Director Jan 1, 2024
Christina Freese Decker Individual Operational/Managerial ControlAdministrator to Cho Oct 1, 2018
Jay V Shah Individual OtherRHC Medical Director Jan 1, 2020
Pamela Garmon Johnson Individual Corporate Director Jan 1, 2022
Deborah L Bennett Berecz Individual Corporate Director Jan 1, 2023
Scott Smith Individual Corporate Director Jan 1, 1995
Amey Upton Individual Corporate Director Mar 24, 2024
Teresa Arlene Treiber Individual W-2 Managing EmployeeManager Nov 1, 2025
Dana Wales Individual Corporate Director Jan 1, 2023
Matthew E Cox Individual Corporate OfficerChief Financial Officer Nov 7, 2025
Bertha King Individual Corporate Director Aug 29, 2023
Stephen L Hempel Individual Corporate Director Jan 1, 2024
Christine Vanlandingham Individual Corporate Director Jan 27, 2010
Carey Martin Individual Corporate Director Jan 1, 2022
Tamila Marlow Individual W-2 Managing Employee Nov 1, 2025
David Schaffer Individual Corporate Director Jan 1, 2022

Owners & managing parties with NPI records 1

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

Practitioners & affiliated clinicians

Practitioners 52

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 52

NPI Registry JSON

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

{
    "created_epoch": "1165190400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1705363200000",
    "number": "1508924770",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 MICHIGAN ST NE # MC845",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495032560",
            "telephone_number": "616-486-6790"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 MEDICAL PARK DR",
            "city": "WATERVLIET",
            "state": "MI",
            "postal_code": "490989225",
            "telephone_number": "269-463-2448",
            "fax_number": "269-463-5351"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKELAND COMMUNITY HOSPITAL WATERVLIET",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "COREWELL HEALTH",
        "enumeration_date": "2006-12-04",
        "last_updated": "2024-01-16",
        "certification_date": "2024-01-16",
        "status": "A",
        "authorized_official_last_name": "COX",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "616-391-0780"
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Emergency Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Corewell Health Watervliet Hospitals",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Watervliet, MI

Sources for this page

Verify at the official NPI Registry.