Provider Demographics
NPI:1396819413
Name:SOUTH WASHINGTON FAMILY MEDICINE PC
Entity type:Organization
Organization Name:SOUTH WASHINGTON FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BUIKEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-392-8035
Mailing Address - Street 1:904 WASHINGTON AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7724
Mailing Address - Country:US
Mailing Address - Phone:616-392-8035
Mailing Address - Fax:616-392-7404
Practice Address - Street 1:904 WASHINGTON AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7724
Practice Address - Country:US
Practice Address - Phone:616-392-8035
Practice Address - Fax:616-392-7404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty