1053623074 NPI number — SPECTRUM HEALTH PRIMARY CARE PARTNERS

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 1053623074 NPI number — SPECTRUM HEALTH PRIMARY CARE PARTNERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM HEALTH PRIMARY CARE PARTNERS
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:
COREWELL HEALTH MEDICAL GROUP WEST
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:
1053623074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MICHIGAN ST NE
Provider Second Line Business Mailing Address:
MC 845
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503-2560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600 BRETON RD SE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
KENTWOOD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49508-5262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-391-9700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KRYWANSKI
Authorized Official First Name:
PAULINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
616-486-2253

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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