Basic Information
| Provider Information | |||||||||
| NPI: | 1801219993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECTRUM HEALTH PRIMARY CARE PARTNERS | ||||||||
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| OtherOrganizationName: | SPECTRUM HEALTH MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 2900 BRADFORD ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162767060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2014 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | KRYWANSKI | ||||||||
| AuthorizedOfficialFirstName: | PAULINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6164862253 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECTRUM HEALTH PRIMARY CARE PARTNERS | ||||||||
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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 | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.