1396819413 NPI number — SOUTH WASHINGTON FAMILY MEDICINE 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 1396819413 NPI number — SOUTH WASHINGTON FAMILY MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH WASHINGTON FAMILY MEDICINE 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:
1396819413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
904 WASHINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49423-7724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-392-8035
Provider Business Mailing Address Fax Number:
616-392-7404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423-7724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-392-8035
Provider Business Practice Location Address Fax Number:
616-392-7404
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUIKEMA
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
ELAINE
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
616-392-8035

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; 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