Provider Demographics
NPI:1902086689
Name:UNIVERSITY MEDICAL SPECIALTIES, PC
Entity Type:Organization
Organization Name:UNIVERSITY MEDICAL SPECIALTIES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAEANN
Authorized Official - Middle Name:DANENE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-473-2222
Mailing Address - Street 1:9045 US HIGHWAY 31
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1804
Mailing Address - Country:US
Mailing Address - Phone:269-473-2222
Mailing Address - Fax:269-473-6880
Practice Address - Street 1:9045 US HIGHWAY 31
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1804
Practice Address - Country:US
Practice Address - Phone:269-473-2222
Practice Address - Fax:269-473-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILH009414103T00000X
MIFK271098103T00000X
MINC007536103T00000X
MIDR064962207Q00000X
MILH052398207Q00000X
MIKK081055207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680A112130OtherGROUP MENTAL HEALTH BCBSM PIN
MI700A146860OtherMEDICAL GROUP BCBSM PIN
MI700A146860OtherMEDICAL GROUP BCBSM PIN