Basic Information
| Provider Information | |||||||||
| NPI: | 1154377794 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY EMERGENCY PHYSICIANS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3371 CLEVELAND ROAD EXT | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466289780 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5215 HOLY CROSS PKWY | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743355000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | DEJONG | ||||||||
| AuthorizedOfficialFirstName: | KURTIS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5743355000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100221820 | 05 | IN | MEDICAID |