Basic Information
| Provider Information | |||||||||
| NPI: | 1003850686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST STE M-206C | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556182676 | ||||||||
| FaxNumber: | 2694888284 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST STE M-206C | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556182676 | ||||||||
| FaxNumber: | 2694888284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301059500 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 4301059500 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1003850686 | 05 | MI | MEDICAID | 110174 | 01 | GREAT LAKES HLTH PLN | OTHER | 4290938-10 | 05 | MI | MEDICAID | 200C910540 | 01 | MI | BCBS GRP PIN | OTHER | 2003905471 | 01 | MI | BCBS IND PIN | OTHER | 5315705 | 01 | AETNA PIN | OTHER |