Provider Demographics
NPI:1740391523
Name:COUNTY OF KALAMAZOO
Entity Type:Organization
Organization Name:COUNTY OF KALAMAZOO
Other - Org Name:KALAMAZOO COUNTY HEALTH & COMMUNITY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HOMNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-373-5200
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:MI
Mailing Address - Zip Code:49074-0042
Mailing Address - Country:US
Mailing Address - Phone:269-373-5200
Mailing Address - Fax:269-373-5363
Practice Address - Street 1:3299 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1281
Practice Address - Country:US
Practice Address - Phone:269-373-5259
Practice Address - Fax:269-373-5292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI744571714Medicaid
MIOP390039OtherM-CARE
MIP00055287OtherMEDICARE RR PTAN
MI0C90266OtherBCBSM
MI1103300800OtherMEDICARE RR PCN
MI164490661Medicaid
MI6004860OtherMOLINA HEALTHCARE
MI771860393Medicaid
MI235100484Medicaid
MI88138OtherDELTA DENTAL
MIF25003Medicare UPIN
MI0C91000Medicare PIN