Provider Demographics
NPI:1376586164
Name:MICHIGAN UROLOGICAL CLINIC
Entity Type:Organization
Organization Name:MICHIGAN UROLOGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAATMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-956-9577
Mailing Address - Street 1:4047 SALADIN DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6249
Mailing Address - Country:US
Mailing Address - Phone:616-956-9577
Mailing Address - Fax:616-956-3090
Practice Address - Street 1:4047 SALADIN DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6249
Practice Address - Country:US
Practice Address - Phone:616-956-9577
Practice Address - Fax:616-956-3090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI696208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376586164OtherNPI
MI1376586164OtherNPI