MEDICARE: MICHIGAN UROLOGICAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	696	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1376586164	OTHER	MI	NPI

General Provider Information

NPI Number	:	1376586164
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN UROLOGICAL CLINIC

Provider Business Mailing Address
First Line	:	4047 SALADIN DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6249
Country	:	US
Telephone Number	:	616-956-9577
Fax Number	:	616-956-3090

Provider Business Practice Location Address
First Line	:	4047 SALADIN DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-6249
Country	:	US
Telephone Number	:	616-956-9577
Fax Number	:	616-956-3090

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JILL MAATMAN
Credential	:
Telephone Number	:	616-956-9577

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	06/09/2008

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Practice Location Address:

4065 E HILLS CT SE
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49546-6249

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Practice Fax:

1376501502 — DR. THOMAS J MAATMAN D.O.
Practice Location Address:

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1801854039 — KENNETH F SHOCKLEY D.O.
Practice Location Address:

4047 E HILLS CT SE
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49546-6249

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1831131226 — MICHAEL R. JARVIS, DO PC
Practice Location Address:

4047 SALADIN DR SE
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49546-6249

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1518070663 — CHRISTOPHER MICHEAL LAFLURE PA-C
Practice Location Address:

4047 E HILLS CT SE
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49546-6249

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1194006080 — PAMELA JEAN CLEVENGER MS,OTRL
Practice Location Address:

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Directions to “MICHIGAN UROLOGICAL CLINIC ” Practice Location

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