Healthcare Provider Details

I. General information

NPI: 1831752674
Provider Name (Legal Business Name): EPMG SOUTHWEST MICHIGAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 N SAINT JOSEPH AVE
NILES MI
49120-2207
US

IV. Provider business mailing address

1525 NW 62ND ST
FT LAUDERDALE FL
33309-1831
US

V. Phone/Fax

Practice location:
  • Phone: 269-683-5510
  • Fax:
Mailing address:
  • Phone: 973-251-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN VAUGHN
Title or Position: OFFICER
Credential:
Phone: 404-450-4684