1972511400 NPI number — WENDY SUE BALIVET MD

Table of content: WENDY SUE BALIVET MD (NPI 1972511400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972511400 NPI number — WENDY SUE BALIVET MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALIVET
Provider First Name:
WENDY
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
UTLEY
Provider Other First Name:
WENDY
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1972511400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 STATE ST SE
Provider Second Line Business Mailing Address:
STE 228
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:
616-685-1808
Provider Business Mailing Address Fax Number:
616-685-1850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10047 CROSSROAD CT SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALEDONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-685-8850
Provider Business Practice Location Address Fax Number:
616-891-9494
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  4301075957 , 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: 4679253 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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