1528182656 NPI number — BENTON HARBOR HEALTH CENTER PLLC

Table of content: (NPI 1528182656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528182656 NPI number — BENTON HARBOR HEALTH CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENTON HARBOR HEALTH CENTER PLLC
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:
1528182656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
687 E EMPIRE AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BENTON HARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49022-4857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-926-8535
Provider Business Mailing Address Fax Number:
269-926-8528

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
687 E EMPIRE AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BENTON HARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49022-4857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-926-8535
Provider Business Practice Location Address Fax Number:
269-926-8528
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TYNES
Authorized Official First Name:
DON
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
269-926-8535

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301065652 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10-4662247 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4301065652 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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