1619028412 NPI number — INTERNAL MEDICINE OF WEST MICHIGAN PLLC

Table of content: (NPI 1619028412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619028412 NPI number — INTERNAL MEDICINE OF WEST MICHIGAN PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE OF WEST MICHIGAN PLLC
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:
DR'S MARVIN, GANS AND ROSLANIEC
Provider Other Organization Name Type Code:
4
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:
1619028412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 EAGLE PARK DR NE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49525-7057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-285-9090
Provider Business Mailing Address Fax Number:
616-285-7947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 EAGLE PARK DR NE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525-7057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-285-9090
Provider Business Practice Location Address Fax Number:
616-285-7947
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROSLANIEC
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
616-285-9090

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , 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)

  • Identifier: G02811 . This is a "BLUE CROSS GROUP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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