Basic Information
| Provider Information | |||||||||
| NPI: | 1093768244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVACECE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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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: | 300 LAFAYETTE AVE SE | ||||||||
| Address2: | SUITE 4200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166856922 | ||||||||
| FaxNumber: | 6166855105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/26/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101013293 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3364634 | 05 | MI | MEDICAID | 4597031 | 05 | MI | MEDICAID | 3290666 | 05 | MI | MEDICAID | 3415564 | 05 | MI | MEDICAID | 3495251 | 05 | MI | MEDICAID | 4878391 | 05 | MI | MEDICAID |