NPIMap

Organization Active NPI

Pennock Hospital

  • Rural Health Clinic/Center
  • Lake Odessa, MI
National Provider Identifier
1962889584
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
Practice address
4294 Laurel Dr
Lake Odessa, MI 48849-8430
Phone
(616) 374-7660
Fax
(616) 374-0270
NPI assigned
May 4, 2015
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 Primary

Addresses

Primary practice location

4294 Laurel Dr
Lake Odessa, MI 48849-8430

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
238675OtherMIMEDICARE PTAN

Other names 2

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

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180928001557 MI Part A Provider - Rural Health Clinic 4587551015 Practice locations: Lake Odessa, MI

Rural health clinic certification: CCN 238675

Legal name
PENNOCK HOSPITAL
Doing business as
COREWELL HEALTH PENNOCK HOSPITAL FAMILY MEDICINE-LAKE ODESSA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 1, 2015
Last certification
May 1, 2015
Ownership / control type
2B
Organization structure
CorporationNon-profit
Enrollment address
4294 Laurel Dr
Lake Odessa, MI 48849-8430
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).

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
OtherPresident and Ceo Sep 1, 2018
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

Practitioners & affiliated clinicians

Practitioners 79

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

View all 79

NPI Registry JSON

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

{
    "created_epoch": "1430697600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692748800000",
    "number": "1962889584",
    "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": "4294 LAUREL DR",
            "city": "LAKE ODESSA",
            "state": "MI",
            "postal_code": "488498430",
            "telephone_number": "616-374-7660",
            "fax_number": "616-374-0270"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENNOCK HOSPITAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PENNOCK HOSPITAL",
        "enumeration_date": "2015-05-04",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "238675",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Corewell Health Pennock Hospital Family Medicine - Lake Odessa",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Spectrum Health Pennock Family Medicine - Lake Odessa",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Odessa, MI

Sources for this page

Verify at the official NPI Registry.