Basic Information
| Provider Information | |||||||||
| NPI: | 1790004109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTH MANAGEMENT COSULTIONS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | REDICARE SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6910 S CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489116912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176944134 | ||||||||
| FaxNumber: | 5179083981 | ||||||||
| Practice Location | |||||||||
| Address1: | 6910 S CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489116912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176944134 | ||||||||
| FaxNumber: | 5179083981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2010 | ||||||||
| LastUpdateDate: | 05/25/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5176944134 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DP008207 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700C361780 | 01 | MI | BLUE CROSS ID | OTHER |