Basic Information
| Provider Information | |||||||||
| NPI: | 1477154458 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM HEALTH PRIMARY CARE PARTNERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
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| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 749 PHILLIPS ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490901842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164948724 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | LACEY | ||||||||
| AuthorizedOfficialFirstName: | ELISABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MGR | ||||||||
| AuthorizedOfficialTelephone: | 6164866630 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.