Provider Demographics
NPI:1033226402
Name:GRAND VALLEY MEDICAL SPECIALISTS PLC
Entity Type:Organization
Organization Name:GRAND VALLEY MEDICAL SPECIALISTS PLC
Other - Org Name:GRAND VALLEY INTERNAL MEDICINE SPECIALISTS, PLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-235-4800
Mailing Address - Street 1:1000 EAST PARIS AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:616-459-3158
Mailing Address - Fax:616-742-6758
Practice Address - Street 1:1000 EAST PARIS AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:616-459-3158
Practice Address - Fax:616-742-6758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16122Medicare PIN