Provider Demographics
NPI:1336130848
Name:PROFESSIONAL MED TEAM
Entity Type:Organization
Organization Name:PROFESSIONAL MED TEAM
Other - Org Name:PROFESSIONAL MED TEAM
Other - Org Type:Other Name
Authorized Official - Title/Position:A/R MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-720-1401
Mailing Address - Street 1:965 FORK ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-3257
Mailing Address - Country:US
Mailing Address - Phone:231-720-1804
Mailing Address - Fax:231-720-1805
Practice Address - Street 1:965 FORK ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3257
Practice Address - Country:US
Practice Address - Phone:231-720-1804
Practice Address - Fax:231-720-1805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6110043416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1703598Medicaid
MI1F0001Medicare ID - Type Unspecified