Provider Demographics
NPI:1356379374
Name:HEALTHCARE MIDWEST PC
Entity type:Organization
Organization Name:HEALTHCARE MIDWEST PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCKERNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-373-4646
Mailing Address - Street 1:4613 W MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2645
Mailing Address - Country:US
Mailing Address - Phone:269-488-8360
Mailing Address - Fax:269-488-8359
Practice Address - Street 1:4613 W MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2645
Practice Address - Country:US
Practice Address - Phone:269-488-8360
Practice Address - Fax:269-488-8359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7173604OtherAETNA PIN
MI0N74060Medicare ID - Type Unspecified