1912471863 NPI number — CATHERINE A VANDEWEGE LLC

Table of content: (NPI 1912471863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912471863 NPI number — CATHERINE A VANDEWEGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CATHERINE A VANDEWEGE LLC
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:
1912471863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2250 SYLVAN 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:
49506-5253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-574-4098
Provider Business Mailing Address Fax Number:
313-202-8257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MONROE AVE NW STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49503-1448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-574-4098
Provider Business Practice Location Address Fax Number:
313-202-8257
Provider Enumeration Date:
01/14/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HINTON VANDEWEGE
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
616-574-4098

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1225245517 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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