Basic Information
| Provider Information | |||||||||
| NPI: | 1538299631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASCENSION MEDICAL GROUP PROMED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 SHAFFER ST STE 2 | ||||||||
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| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490481623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2695522836 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7895 CURRIER DR | ||||||||
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| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490024314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693217120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DAMON | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2692265607 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110C910220 | 01 | MI | BCBSM GROUP # | OTHER |