Provider Demographics
NPI:1801818752
Name:BRONSON PRACTICE MANAGEMENT
Entity Type:Organization
Organization Name:BRONSON PRACTICE MANAGEMENT
Other - Org Name:BRONSON PRACTICE MANAGEMENT NURSE PRACTITIONERS & PHYSICIAN ASSISTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP LEGAL AFFAIRS, CLO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:FALAHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6000
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:269-341-8143
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 42
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-7806
Practice Address - Fax:269-341-8143
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONSON PRACTICE MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-23
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI500C912770OtherBCBSM
MI500C912770OtherBCBSM