1184814824 NPI number — MICHIGAN PEDIATRIC HOSPITALIST, PC

Table of content: (NPI 1184814824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184814824 NPI number — MICHIGAN PEDIATRIC HOSPITALIST, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN PEDIATRIC HOSPITALIST, PC
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:
1184814824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
926 WASHINGTON AVE
Provider Second Line Business Mailing Address:
BUILDING C
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49423-7725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-393-0166
Provider Business Mailing Address Fax Number:
616-393-8821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
BOVEN BIRTH CENTER
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-393-0166
Provider Business Practice Location Address Fax Number:
616-393-8821
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VANDENBOSCH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
616-393-0166

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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