Basic Information
| Provider Information | |||||||||
| NPI: | 1497727168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST MICHIGAN RHUEMATOLOGY CENTER,P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694080990 | ||||||||
| FaxNumber: | 2694080993 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694080990 | ||||||||
| FaxNumber: | 2694080993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| AuthorizedOfficialLastName: | CASAS | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2696840259 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301084645 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | DC9447 | 01 | MEDICARE - RR | OTHER |