1477516110 NPI number — PEDIATRIC SURGEONS OF WEST MICHIGAN PC

Table of content: (NPI 1477516110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477516110 NPI number — PEDIATRIC SURGEONS OF WEST MICHIGAN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC SURGEONS OF WEST MICHIGAN PC
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:
Provider Other Organization Name Type Code:
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:
1477516110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 BARCLAY NE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-458-1722
Provider Business Mailing Address Fax Number:
616-458-0061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 BARCLAY NE
Provider Second Line Business Practice Location Address:
SUITE 202
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-458-1722
Provider Business Practice Location Address Fax Number:
616-458-0061
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JAMULA
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
616-458-1722

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 020D176760 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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