Basic Information
Provider Information | |||||||||
NPI: | 1134158249 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WOMENS MEDICAL CENTER, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1201 SOUTH DR | ||||||||
Address2: | SUITE 220 | ||||||||
City: | MT PLEASANT | ||||||||
State: | MI | ||||||||
PostalCode: | 488583256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897733411 | ||||||||
FaxNumber: | 9897753187 | ||||||||
Practice Location | |||||||||
Address1: | 1201 SOUTH DR | ||||||||
Address2: | SUITE 220 | ||||||||
City: | MT PLEASANT | ||||||||
State: | MI | ||||||||
PostalCode: | 488583256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897733411 | ||||||||
FaxNumber: | 9897753187 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PODOLSKY | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | OWEN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9897733411 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 160C71016 | 01 | MI | BCBS GROUP # | OTHER |