1093936999 NPI number — HEALTHCARE MIDWEST PC

Table of content: (NPI 1093936999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093936999 NPI number — HEALTHCARE MIDWEST PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHCARE MIDWEST 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:
6
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:
1093936999
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4341 S WESTNEDGE AVE
Provider Second Line Business Mailing Address:
SUITE 2205
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49008-3289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-373-4646
Provider Business Mailing Address Fax Number:
269-373-7655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4613 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49006-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-488-8672
Provider Business Practice Location Address Fax Number:
269-488-8673
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCKERNAN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
269-373-4646

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 110C913020 . This is a "BLUE CROSS GRP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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