Basic Information
| Provider Information | |||||||||
| NPI: | 1770587305 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVIC | ||||||||
| FirstName: | JOSIP | ||||||||
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| Credential: | MD | ||||||||
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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: | 100 MICHIGAN ST NE | ||||||||
| Address2: | A721 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163913139 | ||||||||
| FaxNumber: | 6163913044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301062325 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4198690 | 05 | MI | MEDICAID |