Basic Information
| Provider Information | |||||||||
| NPI: | 1952373623 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIABETES AND ENDOCRINOLOGY CENTER OF SOUTHWEST MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 284 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694080990 | ||||||||
| FaxNumber: | 2694080992 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 284 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694080990 | ||||||||
| FaxNumber: | 2694080992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MIDDLETON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | GEEGAN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2696840259 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 4301076224 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.