Provider Demographics
NPI:1831470285
Name:KALMAZOO GASTROENTEROLOGY HEPATOLOGY AND DIGESTIVE HEALTH CENTER
Entity Type:Organization
Organization Name:KALMAZOO GASTROENTEROLOGY HEPATOLOGY AND DIGESTIVE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:LINCOLN
Authorized Official - Last Name:PRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:269-385-9900
Mailing Address - Street 1:1535 GULL RD STE 105
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1630
Mailing Address - Country:US
Mailing Address - Phone:269-385-9900
Mailing Address - Fax:269-385-2140
Practice Address - Street 1:1535 GULL RD STE 105
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1630
Practice Address - Country:US
Practice Address - Phone:269-385-9900
Practice Address - Fax:269-385-2140
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARAGON HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006118363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty