Basic Information
| Provider Information | |||||||||
| NPI: | 1033416474 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM HEALTH PRIMARY CARE PARTNERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC 845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866795 | ||||||||
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| Practice Location | |||||||||
| Address1: | 418 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | LAKEVIEW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488509806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893528452 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2011 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | KRYWANSKI | ||||||||
| AuthorizedOfficialFirstName: | POLLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6164862253 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECTRUM HEALTH PRIMARY CARE PARTNERS | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084S0012X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
No ID Information.