Healthcare Provider Details

I. General information

NPI: 1093936999
Provider Name (Legal Business Name): HEALTHCARE MIDWEST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4613 W MAIN ST SUITE A
KALAMAZOO MI
49006-2645
US

IV. Provider business mailing address

4341 S WESTNEDGE AVE SUITE 2205
KALAMAZOO MI
49008-3289
US

V. Phone/Fax

Practice location:
  • Phone: 269-488-8672
  • Fax: 269-488-8673
Mailing address:
  • Phone: 269-373-4646
  • Fax: 269-373-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES E MCKERNAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 269-373-4646