Basic Information
| Provider Information | |||||||||
| NPI: | 1902086689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY MEDICAL SPECIALTIES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9045 US HIGHWAY 31 | ||||||||
| Address2: | |||||||||
| City: | BERRIEN SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491031804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694732222 | ||||||||
| FaxNumber: | 2694736880 | ||||||||
| Practice Location | |||||||||
| Address1: | 9045 US HIGHWAY 31 | ||||||||
| Address2: | |||||||||
| City: | BERRIEN SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491031804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694732222 | ||||||||
| FaxNumber: | 2694736880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 10/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | RAEANN | ||||||||
| AuthorizedOfficialMiddleName: | DANENE | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2694732222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | LH052398 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | KK081055 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | KK081055 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 103T00000X | LH009414 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | FK271098 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | NC007536 | MI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207Q00000X | DR064962 | MI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 680A112130 | 01 | MI | GROUP MENTAL HEALTH BCBSM PIN | OTHER | 700A146860 | 01 | MI | MEDICAL GROUP BCBSM PIN | OTHER |