Healthcare Provider Details

I. General information

NPI: 1952413403
Provider Name (Legal Business Name): SOUTH HAVEN FAMILY PHYSICIANS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 BLUE STAR HWY
SOUTH HAVEN MI
49090-7758
US

IV. Provider business mailing address

930 BLUE STAR HWY
SOUTH HAVEN MI
49090-7758
US

V. Phone/Fax

Practice location:
  • Phone: 269-637-1115
  • Fax: 269-639-1314
Mailing address:
  • Phone: 269-637-1115
  • Fax: 269-639-1314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CAROL L RETBERG
Title or Position: PRACTICE ADMINISTRATOR
Credential: R.N.
Phone: 269-637-1115