Basic Information
Provider Information | |||||||||
NPI: | 1154761773 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOPAEDIC ASSOCIATES OF GRAND RAPIDS, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ORTHOPAEDIC ASSOCIATES OF MICHIGAN, PC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495256406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6164597101 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 555 MIDTOWNE ST NE | ||||||||
Address2: | SUITE 105 | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495035729 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6164597101 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2013 | ||||||||
LastUpdateDate: | 09/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | JOEL | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | REVENUE CYCLE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6164597101 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 335E00000X |   |   | N |   | Suppliers | Prosthetic/Orthotic Supplier |   | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | OD14869 | 01 | MI | PTAN | OTHER |