Provider Demographics
NPI:1164470472
Name:GRAND RIVER GASTROENTEROLOGY PC
Entity Type:Organization
Organization Name:GRAND RIVER GASTROENTEROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUMISEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-752-6529
Mailing Address - Street 1:310 LAFAYETTE AVE SE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4693
Mailing Address - Country:US
Mailing Address - Phone:616-752-6525
Mailing Address - Fax:616-752-6556
Practice Address - Street 1:310 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 400
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4693
Practice Address - Country:US
Practice Address - Phone:616-752-6525
Practice Address - Fax:616-752-6556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty