Provider Demographics
NPI:1497727168
Name:SOUTHWEST MICHIGAN RHUEMATOLOGY CENTER,P.C.
Entity Type:Organization
Organization Name:SOUTHWEST MICHIGAN RHUEMATOLOGY CENTER,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CASAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-684-0259
Mailing Address - Street 1:3950 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9151
Mailing Address - Country:US
Mailing Address - Phone:269-408-0990
Mailing Address - Fax:269-408-0993
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 280
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9151
Practice Address - Country:US
Practice Address - Phone:269-408-0990
Practice Address - Fax:269-408-0993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084645174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC9447OtherMEDICARE - RR
MIOP01930Medicare ID - Type UnspecifiedMEDICARE GROUP#