Basic Information
| Provider Information | |||||||||
| NPI: | 1487825006 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROMED HEALTHCARE NURSE PRACTITIONERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5943 STADIUM DR | ||||||||
| Address2: | STE 1 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490093016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695522836 | ||||||||
| FaxNumber: | 2695522964 | ||||||||
| Practice Location | |||||||||
| Address1: | 5943 STADIUM DR | ||||||||
| Address2: | STE 1 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490093016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695522836 | ||||||||
| FaxNumber: | 2695522964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | MILLERMAIER | ||||||||
| AuthorizedOfficialFirstName: | ED | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2695522898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LX0001X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0M92480 | 01 | MI | MEDICARE GROUP # | OTHER |