Provider Demographics
NPI:1497709869
Name:ASCENSION MEDICAL GROUP PROMED
Entity Type:Organization
Organization Name:ASCENSION MEDICAL GROUP PROMED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-226-4800
Mailing Address - Street 1:1717 SHAFFER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1623
Mailing Address - Country:US
Mailing Address - Phone:269-226-5607
Mailing Address - Fax:
Practice Address - Street 1:7901 ANGLING RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0714
Practice Address - Country:US
Practice Address - Phone:269-552-2912
Practice Address - Fax:269-552-2835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No251J00000XAgenciesNursing CareGroup - Multi-Specialty