1568440139 NPI number — SPECTRUM HEALTH KENT COMMUNITY CAMPUS

Table of content: (NPI 1568440139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568440139 NPI number — SPECTRUM HEALTH KENT COMMUNITY CAMPUS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECTRUM HEALTH KENT COMMUNITY CAMPUS
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:
1568440139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 FULLER AVE NE
Provider Second Line Business Mailing Address:
MC 160
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:
616-643-9083
Provider Business Mailing Address Fax Number:
616-643-9060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 FULLER AVE NE
Provider Second Line Business Practice Location Address:
MC 160
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:
616-486-2411
Provider Business Practice Location Address Fax Number:
616-486-2419
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OBERST
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SHCC/DIRECTOR OF FINANCE
Authorized Official Telephone Number:
616-486-2405

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  410090 , 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: 405170970 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00322 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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