Provider Demographics
NPI:1316134976
Name:MATERNAL INFANT HEALTH PROGRAM
Entity type:Organization
Organization Name:MATERNAL INFANT HEALTH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-349-2641
Mailing Address - Street 1:117 W PATERSON ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-2557
Mailing Address - Country:US
Mailing Address - Phone:269-349-2641
Mailing Address - Fax:
Practice Address - Street 1:117 W PATERSON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-2557
Practice Address - Country:US
Practice Address - Phone:269-349-2641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MI430063404171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4784295Medicaid