Basic Information
| Provider Information | |||||||||
| NPI: | 1003822412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRONSON METHODIST HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRONSON METHODIST HOSPITAL NURSE PRACTITIONERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | BOX 42 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693418419 | ||||||||
| FaxNumber: | 2693418743 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | BOX 42 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417979 | ||||||||
| FaxNumber: | 2693416261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FALAHEE | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP LEGAL AFFAIRS, CLO | ||||||||
| AuthorizedOfficialTelephone: | 2693416000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRONSON METHODIST HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 500C961050 | 01 | MI | BCBSM | OTHER |