NPIMap

Organization Active NPI

Pennock State Street Center

  • Medical Physician Assistant
  • Hastings, MI
National Provider Identifier
1932490885
Registry record updated Apr 2, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
Legal business name
PENNOCK STATE STREET CENTER
Practice address
1108 W State St
Hastings, MI 49058-9711
Phone
(269) 948-3360
NPI assigned
Apr 27, 2011
Last updated
Apr 2, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 2, 2019

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

Authorized official

Name
Amy PoholskiNPI 1841220027
Title
Director
Phone
(616) 975-1845

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X NU Primary
Family Nurse Practitioner 363LF0000X NU

Addresses

Primary practice location

1108 W State St
Hastings, MI 49058-9711

Mailing address

4100 Embassy Dr SE
Suite 200
Grand Rapids, MI 49546-2416
Phone (616) 975-1845

Other identifiers 1

IdentifierTypeStateIssuer
0Z80041OtherMIBCBS

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1303862400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1554163200000",
    "number": "1932490885",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4100 EMBASSY DR SE",
            "address_2": "SUITE 200",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495462416",
            "telephone_number": "616-975-1845",
            "fax_number": "616-285-0846"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1108 W STATE ST",
            "city": "HASTINGS",
            "state": "MI",
            "postal_code": "490589711",
            "telephone_number": "269-948-3360"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENNOCK STATE STREET CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-27",
        "last_updated": "2019-04-02",
        "status": "A",
        "authorized_official_last_name": "POHOLSKI",
        "authorized_official_first_name": "AMY",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "616-975-1845"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "0Z80041",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Hastings, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.