1255490397 NPI number — MACATAWA SURGICAL ASSOCIATES PC

Table of content: (NPI 1255490397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255490397 NPI number — MACATAWA SURGICAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MACATAWA SURGICAL ASSOCIATES 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:
1255490397
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 77000
Provider Second Line Business Mailing Address:
DEPT 77138
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48277-0138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-994-6677
Provider Business Mailing Address Fax Number:
616-994-6683

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3290 N WELLNESS DR STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49424-8047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-994-6677
Provider Business Practice Location Address Fax Number:
616-994-6683
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHRAM
Authorized Official First Name:
JON
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
616-994-6677

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com