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General NPI Number Information
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NPI Number | 1831470285
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Entity Type | Organization
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Legal Business Name | KALMAZOO GASTROENTEROLOGY HEPATOLOGY AND DIGESTIVE HEALTH CENTER
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Dates
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Enumeration Date | 08/30/2011
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Last Update Date | 08/30/2011
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Provider Practice Location Address
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Address Line | 1535 GULL RD STE 105
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City | KALAMAZOO
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State | MI
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Zip | 49048-1630
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Country | US
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Telephone | 269-385-9900
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Fax | 269-385-2140
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Provider Business Mailing Address
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Address Line | 1535 GULL RD STE 105
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City | KALAMAZOO
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State | MI
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Zip | 49048-1630
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Country | US
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Telephone | 269-385-9900
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Fax | 269-385-2140
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | MR. LANCE LINCOLN PRIDE
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Credential | PAC
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Telephone | 269-385-9900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5601006118
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License Number State | MI
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