1851324610 NPI number — GRAND RAPIDS FERTILITY & IVF, PC

Table of content: DR. JAMES LEE JACOBSON M.D. (NPI 1518987619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851324610 NPI number — GRAND RAPIDS FERTILITY & IVF, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND RAPIDS FERTILITY & IVF, 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:
1851324610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 MID TOWNE ST NE
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:
49503-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-774-2030
Provider Business Mailing Address Fax Number:
616-774-2053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 MID TOWNE ST NE
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:
49503-2515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-774-2030
Provider Business Practice Location Address Fax Number:
616-774-2053
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DALY
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
CHAPMAN
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
616-774-2030

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X , with the licence number:  4301057122 , 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: 2807935 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 106052 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1604114301 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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