Basic Information
| Provider Information | |||||||||
| NPI: | 1013021310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWESTERN MICHIGAN EMERGENCY SERVICES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 S KALAMAZOO MALL | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490074832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987139 | ||||||||
| FaxNumber: | 6169759827 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 S KALAMAZOO MALL | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490074832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987139 | ||||||||
| FaxNumber: | 6169759827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | DEMOSS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2693433900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 700H01007 | 01 | MI | BCBS | OTHER | 700Z310360 | 01 | MI | BCBS | OTHER | CC0530 | 01 | MI | RR MEDICARE | OTHER | DC9527 | 01 | RR MEDICARE | OTHER | 010C96159 | 01 | MI | BCBS | OTHER | CN1229 | 01 | MI | RR MEDICARE | OTHER |