1184814824 NPI number — MICHIGAN PEDIATRIC HOSPITALIST, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184814824 NPI number — MICHIGAN PEDIATRIC HOSPITALIST, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIGAN PEDIATRIC HOSPITALIST, 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:
1184814824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
926 WASHINGTON AVE
Provider Second Line Business Mailing Address:
BUILDING C
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49423-7725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-393-0166
Provider Business Mailing Address Fax Number:
616-393-8821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
BOVEN BIRTH CENTER
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-393-0166
Provider Business Practice Location Address Fax Number:
616-393-8821
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VANDENBOSCH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
616-393-0166

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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