Provider Demographics
NPI:1104840529
Name:BRONSON PRACTICE MANAGEMENT
Entity Type:Organization
Organization Name:BRONSON PRACTICE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP LEGAL AFFAIRS, CLO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:FALAHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6000
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 42
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONSON PRACTICE MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-27
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 207V00000X, 208000000X, 208600000X
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA1068OtherRAILROAD MEDICARE
MICB9054OtherRAILROAD MEDICARE
MICN1148OtherRAILROAD MEDICARE
MI0C910950OtherBCBSM
MIC30861OtherRAILROAD MEDICARE
MICC3543OtherRAILROAD MEDICARE
MICA4396OtherRAILROAD MEDICARE
MICB9054OtherRAILROAD MEDICARE
MI0M20520Medicare PIN