Provider Demographics
NPI:1114094349
Name:GREATER GRAND RAPIDS PULMONARY AND CRITICAL CARE SPECIALISTS PC
Entity Type:Organization
Organization Name:GREATER GRAND RAPIDS PULMONARY AND CRITICAL CARE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEERSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-241-3500
Mailing Address - Street 1:2093 HEALTH DR SW
Mailing Address - Street 2:#301
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519
Mailing Address - Country:US
Mailing Address - Phone:616-241-3500
Mailing Address - Fax:616-241-4396
Practice Address - Street 1:2093 HEALTH DR SW
Practice Address - Street 2:#301
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9691
Practice Address - Country:US
Practice Address - Phone:616-241-3500
Practice Address - Fax:616-241-4396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013369207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4540244Medicaid