Basic Information
| Provider Information | |||||||||
| NPI: | 1669698668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH HAVEN ORTHOPEDICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696375271 | ||||||||
| FaxNumber: | 2696392818 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 S BAILEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490909701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696375271 | ||||||||
| FaxNumber: | 2696392818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | URBANSKI | ||||||||
| AuthorizedOfficialFirstName: | JOANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 2696392810 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 80020 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200H01002 | 01 | MI | BCBS | OTHER |