Provider Demographics
NPI:1083014914
Name:ADVANTAGE HEALTH SAINT MARY'S MEDICAL GROUP
Entity Type:Organization
Organization Name:ADVANTAGE HEALTH SAINT MARY'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-685-1800
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6050 NORTHLAND DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9244
Practice Address - Country:US
Practice Address - Phone:616-685-8350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care