1184815417 NPI number — GRAND RAPIDS PLASTIC SURGERY PLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184815417 NPI number — GRAND RAPIDS PLASTIC SURGERY PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND RAPIDS PLASTIC SURGERY PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTRE FOR PLASTIC SURGERY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184815417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
426 MICHIGAN ST
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-5609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-454-1256
Provider Business Mailing Address Fax Number:
616-831-2648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
426 MICHIGAN ST
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-5609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-454-1256
Provider Business Practice Location Address Fax Number:
616-831-2648
Provider Enumeration Date:
08/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNDAGE
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
616-454-1257

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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