Basic Information
| Provider Information | |||||||||
| NPI: | 1124295126 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN MEDICAL PATIENT CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4085 BURTON ST SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495462444 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3152 PORT SHELDON ST | ||||||||
| Address2: | |||||||||
| City: | HUDSONVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494269297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166699238 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2008 | ||||||||
| LastUpdateDate: | 05/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | HARRING | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6169744889 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MICHIGAN MEDICAL PATIENT CARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.