Basic Information
| Provider Information | |||||||||
| NPI: | 1477927184 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECTRUM HEALTH UNITED | ||||||||
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| OtherOrganizationName: | SPECTRUM HEALTH UNITED HOSPITAL INTERNAL MEDICINE, PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 707 S GREENVILLE WEST DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488383514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167543001 | ||||||||
| FaxNumber: | 6167543828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2015 | ||||||||
| LastUpdateDate: | 01/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6162256310 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECTRUM HEALTH UNITED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.