Provider Demographics
NPI:1437187119
Name:COLON MEDICAL CLINIC
Entity type:Organization
Organization Name:COLON MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-432-3221
Mailing Address - Street 1:121 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:COLON
Mailing Address - State:MI
Mailing Address - Zip Code:49040-9363
Mailing Address - Country:US
Mailing Address - Phone:269-432-3221
Mailing Address - Fax:269-432-3120
Practice Address - Street 1:121 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:COLON
Practice Address - State:MI
Practice Address - Zip Code:49040
Practice Address - Country:US
Practice Address - Phone:269-432-3221
Practice Address - Fax:269-432-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILV080959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P23180Medicare PIN