Basic Information
Provider Information | |||||||||
NPI: | 1265653158 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTHCARE MIDWEST PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTHCARE MIDWEST HAND & ELBOW SURGERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4341 S WESTNEDGE AVE | ||||||||
Address2: | SUITE 2205 | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490083289 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693734646 | ||||||||
FaxNumber: | 2693737655 | ||||||||
Practice Location | |||||||||
Address1: | 601 JOHN ST | ||||||||
Address2: | SUITE M230 | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490075341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2693498601 | ||||||||
FaxNumber: | 2693496446 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2007 | ||||||||
LastUpdateDate: | 08/11/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCKERNAN | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 2693734646 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HEALTHCARE MIDWEST, PC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XS0106X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
ID | Type | State | Issuer | Description | 200C910540 | 01 | MI | BLUE CROSS GRP PIN | OTHER |