Provider Demographics
NPI:1184815417
Name:GRAND RAPIDS PLASTIC SURGERY PLC
Entity Type:Organization
Organization Name:GRAND RAPIDS PLASTIC SURGERY PLC
Other - Org Name:CENTRE FOR PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRUNDAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-454-1257
Mailing Address - Street 1:426 MICHIGAN ST
Mailing Address - Street 2:STE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5609
Mailing Address - Country:US
Mailing Address - Phone:616-454-1256
Mailing Address - Fax:616-831-2648
Practice Address - Street 1:426 MICHIGAN ST
Practice Address - Street 2:STE 300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5609
Practice Address - Country:US
Practice Address - Phone:616-454-1256
Practice Address - Fax:616-831-2648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2301029Medicare PIN