Provider Demographics
NPI:1093936999
Name:HEALTHCARE MIDWEST PC
Entity Type:Organization
Organization Name:HEALTHCARE MIDWEST PC
Other - Org Name:LIFETIME WELLNESS IN INTERNAL MEDICINE & PEDIATRICS A DIVISION OF HEAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCKERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-373-4646
Mailing Address - Street 1:4341 S WESTNEDGE AVE
Mailing Address - Street 2:SUITE 2205
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-3289
Mailing Address - Country:US
Mailing Address - Phone:269-373-4646
Mailing Address - Fax:269-373-7655
Practice Address - Street 1:4613 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2645
Practice Address - Country:US
Practice Address - Phone:269-488-8672
Practice Address - Fax:269-488-8673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHCARE MIDWEST, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-01
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110C913020OtherBLUE CROSS GRP PIN
=========OtherEIN-HEALTHCARE MIDWEST