Basic Information
| Provider Information | |||||||||
| NPI: | 1952413403 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH HAVEN FAMILY PHYSICIANS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 BLUE STAR HWY | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490907758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696371115 | ||||||||
| FaxNumber: | 2696391314 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 BLUE STAR HWY | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490907758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696371115 | ||||||||
| FaxNumber: | 2696391314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | RETBERG | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2696371115 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.