Provider Demographics
NPI:1356653182
Name:SPECTRUM HEALTH KELSEY
Entity Type:Organization
Organization Name:SPECTRUM HEALTH KELSEY
Other - Org Name:LAKEVIEW FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-225-6428
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:418 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-7102
Practice Address - Country:US
Practice Address - Phone:989-352-6435
Practice Address - Fax:989-352-8451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health