1063542165 NPI number — ASCENSION MEDICAL GROUP PROMED

Table of content: (NPI 1063542165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063542165 NPI number — ASCENSION MEDICAL GROUP PROMED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASCENSION MEDICAL GROUP PROMED
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:
1063542165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 SHAFFER ST STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49048-1623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-552-2836
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8001 ANGLING RD
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:
49024-7422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-321-7090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOUGHTON
Authorized Official First Name:
MARINA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
269-226-4800

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 750910577 . This is a "BCBSM GROUP #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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