=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215111091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MERCY CARE OF WEST MICHIGAN INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2007
-----------------------------------------------------
Last Update Date | 01/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1560 E SHERMAN BLVD SUITE 125
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-672-3660
-----------------------------------------------------
Fax | 231-672-3630
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1560 E SHERMAN BLVD SUITE 125
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-672-3660
-----------------------------------------------------
Fax | 231-672-3630
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. MELANIE TOWNE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-672-6950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number | 5101012374
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------