Basic Information
| Provider Information | |||||||||
| NPI: | 1811933179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KALAMAZOO ENDO CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 YORK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JAMISON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189291098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155899024 | ||||||||
| FaxNumber: | 8337056301 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 COOLEY COURT | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693213390 | ||||||||
| FaxNumber: | 2693213392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOHLFELD | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2155899024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 396833 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 396833 | 01 | MI | STATE LICENSE | OTHER | 40006 | 01 | BCBSMI | OTHER | BG9518626 | 01 | DEA REGISTRATION | OTHER | 23D1045430 | 01 | CLIA CERTIFICATE WAIVER | OTHER | 70733 | 01 | MI | AAAHC ORGANIZATION NUMBER | OTHER |