Basic Information
| Provider Information | |||||||||
| NPI: | 1760599906 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANTAGE HEALTH/SAINT MARY'S MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 44TH ST SE | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495085008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | 6166858099 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 6166851808 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.