Organization
PENNOCK STATE STREET CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AMY POHOLSKI (DIRECTOR)
(616) 975-1845
Entity
Organization
Contact information
Practice address
1108 W STATE ST, HASTINGS, MI 49058-9711
(269) 948-3360
Mailing address
4100 EMBASSY DR SE, SUITE 200, GRAND RAPIDS, MI 49546-2416
(616) 975-1845
(616) 285-0846
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
—
363LF0000X
Family Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0Z80041
BCBS
MI
Enumeration date
04/27/2011
Last updated
04/02/2019
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