Provider Demographics
NPI:1477640720
Name:WEST MICHIGAN CANCER CENTER
Entity Type:Organization
Organization Name:WEST MICHIGAN CANCER CENTER
Other - Org Name:WEST MICHIGAN CANCER CENTER NURSE PRACTITIONERS AND PAS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-382-2500
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 1:200 N PARK ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3731
Practice Address - Country:US
Practice Address - Phone:264-382-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST MICHIGAN CANCER CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-06
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP167500Medicare PIN