Provider Demographics
NPI:1275524720
Name:GRAND RIVER CARDIOLOGY, PLC
Entity Type:Organization
Organization Name:GRAND RIVER CARDIOLOGY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-949-8554
Mailing Address - Street 1:1000 E PARIS AVE SE
Mailing Address - Street 2:STE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3691
Mailing Address - Country:US
Mailing Address - Phone:616-949-8554
Mailing Address - Fax:616-949-6557
Practice Address - Street 1:1000 E PARIS AVE SE
Practice Address - Street 2:STE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3691
Practice Address - Country:US
Practice Address - Phone:616-949-8554
Practice Address - Fax:616-949-7027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC20434OtherMEDICARE RRR
MIC20434OtherMEDICARE RRR