MEDICARE: DONNA DEWYSE CNM

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	176B00000X	Midwife	4704107758	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	42-0-87-0485-0	OTHER	MI	BCBS PIN

General Provider Information

NPI Number	:	1487652368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA DEWYSE CNM

Provider Business Mailing Address
First Line	:	435 W CENTER RD
Second Line	:
City	:	ESSEXVILLE
State	:	MI
Zip	:	48732-9420
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1142 S VAN DYKE RD
Second Line	:
City	:	BAD AXE
State	:	MI
Zip	:	48413-9800
Country	:	US
Telephone Number	:	989-269-9721
Fax Number	:	989-269-4181

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	07/08/2007

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