Provider Demographics
NPI:1881853901
Name:WESTERN MICHIGAN UNIVERSITY UNIFIED CLINIC
Entity Type:Organization
Organization Name:WESTERN MICHIGAN UNIVERSITY UNIFIED CLINIC
Other - Org Name:CHARLES VAN RIPER SPEECH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:269-387-7005
Mailing Address - Street 1:1000 OAKLAND DR FL 3
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1282
Mailing Address - Country:US
Mailing Address - Phone:269-387-8047
Mailing Address - Fax:269-387-7026
Practice Address - Street 1:1000 OAKLAND DR FL 3
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1282
Practice Address - Country:US
Practice Address - Phone:269-387-8047
Practice Address - Fax:269-387-7026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
46 31868OtherUNITED HEALTH CARE INSURANCE
MI40 4702665Medicaid