Healthcare Provider Details

I. General information

NPI: 1609967157
Provider Name (Legal Business Name): OBGYN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2854 S 11TH STREET
KALAMAZOO MI
49009-2129
US

IV. Provider business mailing address

2854 S 11TH ST
KALAMAZOO MI
49009-2129
US

V. Phone/Fax

Practice location:
  • Phone: 269-345-6197
  • Fax: 269-345-9734
Mailing address:
  • Phone: 269-345-6197
  • Fax: 269-345-9734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: TAMMY DANDO
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 269-345-6197