1386702173 NPI number — PROMED HEALTHCARE

Table of content: (NPI 1386702173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386702173 NPI number — PROMED HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMED HEALTHCARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386702173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5943 STADIUM DR
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49009-3016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-552-2836
Provider Business Mailing Address Fax Number:
269-552-2835

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 S WESTNEDGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49008-3208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-381-3500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MILLERMAIER
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL OFFICER
Authorized Official Telephone Number:
269-552-2910

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)