Provider Demographics
NPI:1245452481
Name:PLASTIC SURGERY OF KALAMAZOO,PC
Entity type:Organization
Organization Name:PLASTIC SURGERY OF KALAMAZOO,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PATIENT ACCOUNTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-372-3000
Mailing Address - Street 1:7901 SOUTH 12TH STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-372-3000
Mailing Address - Fax:269-372-3500
Practice Address - Street 1:7901 SOUTH 12TH STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-372-3000
Practice Address - Fax:269-372-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1997100Medicaid
MI1920114Medicaid
MI1997100Medicaid
MIE19820Medicare UPIN
MIA76947Medicare UPIN
MIOM82180002Medicare ID - Type Unspecified