Provider Demographics
NPI:1285826297
Name:WEST MICHIGAN FAMILY MEDICINE-KENTWOOD, PLC
Entity Type:Organization
Organization Name:WEST MICHIGAN FAMILY MEDICINE-KENTWOOD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-455-4114
Mailing Address - Street 1:2120 43RD ST SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-3772
Mailing Address - Country:US
Mailing Address - Phone:616-455-4114
Mailing Address - Fax:616-455-4454
Practice Address - Street 1:2120 43RD ST SE
Practice Address - Street 2:SUITE 200
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-3772
Practice Address - Country:US
Practice Address - Phone:616-455-4114
Practice Address - Fax:616-455-4454
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST MICHIGAN FAMILY MEDICINE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4092931Medicaid
MI4092969Medicaid
MI4387357Medicaid
MI4092978Medicaid
MIM80080002Medicare PIN
MI4387357Medicaid
MI4092978Medicaid
MI4092931Medicaid
F98016Medicare UPIN
MI4092969Medicaid
MIM80080003Medicare PIN
MIM80080001Medicare PIN