Healthcare Provider Details

I. General information

NPI: 1679520712
Provider Name (Legal Business Name): CRITICAL CARE PULMONARY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 FREMONT ST SUITE 100
BATTLE CREEK MI
49017-3389
US

IV. Provider business mailing address

363 FREMONT ST SUITE 100
BATTLE CREEK MI
49017-3389
US

V. Phone/Fax

Practice location:
  • Phone: 269-969-6100
  • Fax: 269-969-6102
Mailing address:
  • Phone: 269-969-6100
  • Fax: 269-969-6102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: STACY ELAINE ROBERTS V
Title or Position: PRACTICE MANAGER
Credential:
Phone: 269-969-6100