1376868372 NPI number — AMC MOBILE ANESTHESIA, PC

Table of content: (NPI 1376868372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376868372 NPI number — AMC MOBILE ANESTHESIA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMC MOBILE ANESTHESIA, 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:
AMC MOBILE
Provider Other Organization Name Type Code:
5
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:
1376868372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 EVERGREEN DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49525-9493
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-284-3180
Provider Business Mailing Address Fax Number:
616-284-3181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 EVERGREEN DR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525-9493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-284-3180
Provider Business Practice Location Address Fax Number:
616-284-3181
Provider Enumeration Date:
04/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
VANDAM
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
F
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
616-284-3100

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0D10334 . This is a "BCBS GRP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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