Provider Demographics
NPI:1215823323
Name:-
Entity type:Organization
Organization Name:-
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTRUM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-748-7399
Mailing Address - Street 1:2120 GRAND RIVER ANX STE 700
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7391
Mailing Address - Country:US
Mailing Address - Phone:810-206-1776
Mailing Address - Fax:
Practice Address - Street 1:2120 GRAND RIVER ANX STE 700
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7391
Practice Address - Country:US
Practice Address - Phone:810-206-1776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLNESS WITHIN JACKSON II PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty