1023259249 NPI number — SPECTRUM HEALTH PRIMARY CARE PARTNERS

Table of content: (NPI 1023259249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023259249 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:
Provider Other Organization Name Type Code:
6
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:
1023259249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2864
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:
49501-2864
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:
4444 KALAMAZOO AVE SE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49508-4600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-391-3302
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TUCCI
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
616-391-2062

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  4704173499 , 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: 420D121610 . This is a "BCBS GROUP 420D121610" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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