1700855475 NPI number — DR. ANTJE SOUTHWICK DEW MD

Table of content: DR. ANTJE SOUTHWICK DEW MD (NPI 1700855475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700855475 NPI number — DR. ANTJE SOUTHWICK DEW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEW
Provider First Name:
ANTJE
Provider Middle Name:
SOUTHWICK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1700855475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 TIMBER RIDGE DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49301-9359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-682-2045
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3152 PORT SHELDON ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
HUDSONVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49426-9297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-669-9238
Provider Business Practice Location Address Fax Number:
616-669-8296
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  4301078492 , 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)





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