Healthcare Provider Details

I. General information

NPI: 1164744595
Provider Name (Legal Business Name): VAN BUREN COMMUNITY MENTAL HEALTH PHYSICIAN PROFESSIONAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2010
Last Update Date: 02/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 HAZEN STREET SUITE C
PAW PAW MI
49079-0249
US

IV. Provider business mailing address

P.O. BOX 249 801 HAZEN STREET SUITE C
PAW PAW MI
49079-0249
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-5574
  • Fax: 269-657-3474
Mailing address:
  • Phone: 269-657-5574
  • Fax: 269-657-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBRA L.-R. HESS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 269-657-5574