Basic Information
| Provider Information | |||||||||
| NPI: | 1023136405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERIE WEST HOSPICE AND PALLIATIVE CARE, LTD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROMEDICA HOSPICE (MONROE) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1070 N MONROE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481623113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342408939 | ||||||||
| FaxNumber: | 7342408950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1070 N MONROE ST STE B | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481623113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342408939 | ||||||||
| FaxNumber: | 7342408950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 01/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4192525734 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 2849403 | 05 | MI | MEDICAID |