NPI |
1861958076 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Employer Identification Number EIN |
|
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Provider Organization Name Legal Business Name |
PROMEDICA CENTRAL CORPORATION OF MICHIGAN |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider First Line Business Practice Location Address |
324 E MAUMEE ST |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider Business Practice Location Address City Name |
ADRIAN |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
MI |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address Postal Code |
492212961 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Telephone Number |
5172653307 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
2/12/2019 |
The telephone number associated with the location address of the provider being identified. |
Last Update Date |
2/12/2019 |
The date that a record was last updated or changed. |
Authorized Official Last Name |
KNUEVEN |
The date that a record was last updated or changed. |
Authorized Official First Name |
KRISTIN |
The first name of the authorized official. |
Authorized Official Title or Position |
DELEGATED OFFICIAL |
The first name of the authorized official. |
Authorized Official Telephone Number |
5675851969 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
213E00000X |
The 10-position telephone number of the authorized official. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
Y |
|
Parent Organization LBN |
PROMEDICA PHYSICIAN GROUP INC |
|
Parent Organization TIN |
|
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Healthcare Provider Taxonomy Group 1 |
193400000X MULTIPLE SINGLE SPECIALTY GROUP |
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