1467475723 NPI number — KALAMAZOO OPHTHALMOLOGY PC

Table of content: (NPI 1467475723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467475723 NPI number — KALAMAZOO OPHTHALMOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KALAMAZOO OPHTHALMOLOGY 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:
1467475723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3412 W CENTRE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49024-4624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-329-5860
Provider Business Mailing Address Fax Number:
269-329-5865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3412 W CENTRE AVE
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:
49024-4624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-329-5860
Provider Business Practice Location Address Fax Number:
269-329-5865
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HIGGINS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-329-5860

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180C960320 . This is a "BCBS GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: FS003034 . This is a "FERRIS STANDIFORD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1863900012 . This is a "GREGORY BIBART" identifier . This identifiers is of the category "OTHER".
  • Identifier: 900C965580 . This is a "FERRIS STANDIFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: GB072121 . This is a "GREGORY BIBART" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1803906051 . This is a "GREGORY BIBART" identifier . This identifiers is of the category "OTHER".
  • Identifier: SH405954 . This is a "STEPHEN HIGGINS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2669516 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180C910010 . This is a "BCN GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4415148 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1803901811 . This is a "STEPHEN HIGGINS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4073524 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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