Provider Demographics
NPI:1952373623
Name:DIABETES AND ENDOCRINOLOGY CENTER OF SOUTHWEST MICHIGAN
Entity Type:Organization
Organization Name:DIABETES AND ENDOCRINOLOGY CENTER OF SOUTHWEST MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:GEEGAN
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-684-0259
Mailing Address - Street 1:3950 HOLLYWOOD RD
Mailing Address - Street 2:SUITE 284
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9151
Mailing Address - Country:US
Mailing Address - Phone:269-408-0990
Mailing Address - Fax:269-408-0992
Practice Address - Street 1:3950 HOLLYWOOD RD
Practice Address - Street 2:SUITE 284
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9151
Practice Address - Country:US
Practice Address - Phone:269-408-0990
Practice Address - Fax:269-408-0992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076224174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP1807Medicare ID - Type UnspecifiedMEDICARE