Healthcare Provider Details

I. General information

NPI: 1902086689
Provider Name (Legal Business Name): UNIVERSITY MEDICAL SPECIALTIES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9045 US HIGHWAY 31
BERRIEN SPRINGS MI
49103-1804
US

IV. Provider business mailing address

9045 US HIGHWAY 31
BERRIEN SPRINGS MI
49103-1804
US

V. Phone/Fax

Practice location:
  • Phone: 269-473-2222
  • Fax: 269-473-6880
Mailing address:
  • Phone: 269-473-2222
  • Fax: 269-473-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLH009414
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberFK271098
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberNC007536
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR064962
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLH052398
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberKK081055
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberKK081055
License Number StateMI

VIII. Authorized Official

Name: RAEANN DANENE LONG
Title or Position: OFFICE MANAGER
Credential:
Phone: 269-473-2222