Provider Demographics
NPI:1235284076
Name:CREEKSIDE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:CREEKSIDE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-954-0600
Mailing Address - Street 1:358 68TH ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-7179
Mailing Address - Country:US
Mailing Address - Phone:616-281-0463
Mailing Address - Fax:616-281-0576
Practice Address - Street 1:358 68TH ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-7179
Practice Address - Country:US
Practice Address - Phone:616-281-0463
Practice Address - Fax:616-281-0576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194836833OtherNPI CHARLES ANDREWS, M.D.
MI1770545139OtherNPI KELLY SCHROEDER, PA-C
MI1942311600OtherNPI THEODOOR BEELS, M.D.
MIA78015Medicare UPIN
MIP75412Medicare UPIN
MI1770545139OtherNPI KELLY SCHROEDER, PA-C