Provider Demographics
NPI:1528182656
Name:BENTON HARBOR HEALTH CENTER PLLC
Entity Type:Organization
Organization Name:BENTON HARBOR HEALTH CENTER PLLC
Other - Org Name:DON J. TYNES M. D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:J
Authorized Official - Last Name:TYNES
Authorized Official - Suffix:
Authorized Official - Credentials:M,D,
Authorized Official - Phone:269-926-8535
Mailing Address - Street 1:687 E EMPIRE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-4857
Mailing Address - Country:US
Mailing Address - Phone:269-926-8535
Mailing Address - Fax:269-926-8528
Practice Address - Street 1:687 E EMPIRE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-4857
Practice Address - Country:US
Practice Address - Phone:269-926-8535
Practice Address - Fax:269-926-8528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065652174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4662247Medicaid
MI4301065652OtherSTATE LICENSE
MI4301065652OtherSTATE LICENSE
MIH27110Medicare UPIN