Basic Information
| Provider Information | |||||||||
| NPI: | 1366730566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MECOSTA COUNTY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | SPECTRUM HEALTH BIG RAPIDS PROVIDERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
| FaxNumber: | 6164866702 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 LINDEN ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BIG RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493071879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317963200 | ||||||||
| FaxNumber: | 2317965562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2011 | ||||||||
| LastUpdateDate: | 05/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | DAUGHERTY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2315924407 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MECOSTA COUNTY MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363A00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.