1811933179 NPI number — KALAMAZOO ENDO CENTER LLC

Table of content: (NPI 1811933179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811933179 NPI number — KALAMAZOO ENDO CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KALAMAZOO ENDO CENTER LLC
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:
1811933179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 YORK RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMISON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18929-1098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-589-9024
Provider Business Mailing Address Fax Number:
833-705-6301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 COOLEY COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-321-3390
Provider Business Practice Location Address Fax Number:
269-321-3392
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOHLFELD
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CO-TREASURER
Authorized Official Telephone Number:
215-589-9024

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  396833 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 396833 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 40006 . This is a "BCBSMI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 23D1045430 . This is a "CLIA CERTIFICATE WAIVER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 70733 . This is a "AAAHC ORGANIZATION NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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