Basic Information
| Provider Information | |||||||||
| NPI: | 1639407786 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN MICHIGAN UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WMU SINDECUSE HEALTH CENTER LABORATORY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1903 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490085200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693873290 | ||||||||
| FaxNumber: | 2693873204 | ||||||||
| Practice Location | |||||||||
| Address1: | 1903 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490085200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693873290 | ||||||||
| FaxNumber: | 2693873204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2009 | ||||||||
| LastUpdateDate: | 12/01/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | EDDY | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTORY | ||||||||
| AuthorizedOfficialTelephone: | 2693873280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN MICHIGAN UNIVERSITY SINDECUSE HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.