=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235143090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST MICHIGAN NEPHROLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 07/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 MERCY DR SUITE 101
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-1881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-733-1912
-----------------------------------------------------
Fax | 231-737-4603
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 MERCY DR SUITE 101
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-1881
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-733-1912
-----------------------------------------------------
Fax | 231-737-4603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | MS. KATHY HOLTZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-733-1912
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------