=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487825006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMED HEALTHCARE NURSE PRACTITIONERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2008
-----------------------------------------------------
Last Update Date | 03/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5943 STADIUM DR STE 1
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49009-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-552-2836
-----------------------------------------------------
Fax | 269-552-2964
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5943 STADIUM DR STE 1
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49009-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-552-2836
-----------------------------------------------------
Fax | 269-552-2964
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | DR. ED MILLERMAIER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 269-552-2898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LX0001X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------