Provider Demographics
NPI:1376868372
Name:AMC MOBILE ANESTHESIA, PC
Entity Type:Organization
Organization Name:AMC MOBILE ANESTHESIA, PC
Other - Org Name:AMC MOBILE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:F
Authorized Official - Last Name:VANDAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-284-3100
Mailing Address - Street 1:3333 EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9493
Mailing Address - Country:US
Mailing Address - Phone:616-284-3180
Mailing Address - Fax:616-284-3181
Practice Address - Street 1:3333 EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9493
Practice Address - Country:US
Practice Address - Phone:616-284-3180
Practice Address - Fax:616-284-3181
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST MICHIGAN ANESTHESIA ANESTHESIA, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-01
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D10334OtherBCBS GRP PIN
MIMI4229Medicare PIN