1003515008 NPI number — ADVANTAGE HEALTH SAINT MARY'S MEDICAL GROUP

Table of content: (NPI 1003515008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003515008 NPI number — ADVANTAGE HEALTH SAINT MARY'S MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE HEALTH SAINT MARY'S MEDICAL GROUP
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:
TRINITY HEALTH MEDICAL GROUP ORTHOPEDICS GRAND RAPIDS
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:
1003515008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 JEFFERSON AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-4502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-672-2120
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2373 64TH ST SW STE 2700
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BYRON CENTER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49315-7978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-465-5910
Provider Business Practice Location Address Fax Number:
616-465-5911
Provider Enumeration Date:
02/28/2023

Additional Information

Authorized Official

Authorized Official Last Name:
ELLER
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
231-672-2120

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2024 www.npivalidator.com