1942247176 NPI number — SPORTS MEDICINE & JOINT CARE OF WEST MICHIGAN, PLC

Table of content: (NPI 1942247176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942247176 NPI number — SPORTS MEDICINE & JOINT CARE OF WEST MICHIGAN, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS MEDICINE & JOINT CARE OF WEST MICHIGAN, PLC
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:
1942247176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7901 S 12TH ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49024-3831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-978-0444
Provider Business Mailing Address Fax Number:
269-978-0447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7901 S 12TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-3831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-978-0444
Provider Business Practice Location Address Fax Number:
269-978-0447
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHAEFER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
269-978-0444

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 4301061042 , 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)





Copyright © 2007-2025 www.npivalidator.com