Basic Information
| Provider Information | |||||||||
| NPI: | 1073566071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIRTH | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | 6166851850 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 JEFFERSON AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301406882 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4879835 | 05 | MI | MEDICAID | 4662354 | 05 | MI | MEDICAID | 4697117 | 05 | MI | MEDICAID | 4878023 | 05 | MI | MEDICAID | 4816030 | 05 | MI | MEDICAID | 4662292 | 05 | MI | MEDICAID | 4662363 | 05 | MI | MEDICAID | 4662336 | 05 | MI | MEDICAID | 4662345 | 05 | MI | MEDICAID | 4697108 | 05 | MI | MEDICAID | 4662274 | 05 | MI | MEDICAID | 4662283 | 05 | MI | MEDICAID | 4662318 | 05 | MI | MEDICAID | 4878293 | 05 | MI | MEDICAID | 4662309 | 05 | MI | MEDICAID | 4662327 | 05 | MI | MEDICAID |