Basic Information
| Provider Information | |||||||||
| NPI: | 1871777227 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUR FLAGS HEALTH VENTURES,INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 122 GRANT ST | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491202281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696840259 | ||||||||
| FaxNumber: | 2696840189 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 GRANT ST | ||||||||
| Address2: | |||||||||
| City: | NILES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491202281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696840259 | ||||||||
| FaxNumber: | 2696840189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 12/20/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MACK | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | V.P.OPERATIONS & FACILITY MANAGEMEN | ||||||||
| AuthorizedOfficialTelephone: | 2699388399 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LAKELAND REGIONAL HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.