1770540957 NPI number — GRAND RAPIDS FOOT & ANKLES PC

Table of content: (NPI 1770540957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770540957 NPI number — GRAND RAPIDS FOOT & ANKLES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND RAPIDS FOOT & ANKLES 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:
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:
1770540957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4310 LEONARD ST NW
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
WALKER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49534-8447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-453-6329
Provider Business Mailing Address Fax Number:
616-453-1725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W APPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HASTINGS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49058-1810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-945-2606
Provider Business Practice Location Address Fax Number:
269-945-5122
Provider Enumeration Date:
04/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHALLA
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
269-945-2606

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  5901001839 , 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: 3516431 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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