Basic Information
| Provider Information | |||||||||
| NPI: | 1669842308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL CENTER OF WEST MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC 845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7 N ATKINSON DR | ||||||||
| Address2: | |||||||||
| City: | LUDINGTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494311953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318433717 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2015 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | KERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2318452251 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL CENTER OF WEST MICHIGAN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.