Provider Demographics
NPI:1124605910
Name:GRAND RIVER SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:GRAND RIVER SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-488-8800
Mailing Address - Street 1:1090 TROWBRIDGE RD STE A
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5220
Mailing Address - Country:US
Mailing Address - Phone:517-282-0851
Mailing Address - Fax:
Practice Address - Street 1:1090 TROWBRIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5220
Practice Address - Country:US
Practice Address - Phone:517-220-0240
Practice Address - Fax:517-200-4455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical