1952373623 NPI number — DIABETES AND ENDOCRINOLOGY CENTER OF SOUTHWEST MICHIGAN

Table of content: (NPI 1952373623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952373623 NPI number — DIABETES AND ENDOCRINOLOGY CENTER OF SOUTHWEST MICHIGAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETES AND ENDOCRINOLOGY CENTER OF SOUTHWEST MICHIGAN
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:
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NPI Number Information

NPI Number:
1952373623
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:
3950 HOLLYWOOD RD
Provider Second Line Business Mailing Address:
SUITE 284
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-9151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-408-0990
Provider Business Mailing Address Fax Number:
269-408-0992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3950 HOLLYWOOD RD
Provider Second Line Business Practice Location Address:
SUITE 284
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-9151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-408-0990
Provider Business Practice Location Address Fax Number:
269-408-0992
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIDDLETON
Authorized Official First Name:
MARY
Authorized Official Middle Name:
GEEGAN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
269-684-0259

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301076224 , 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)





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