Provider Demographics
NPI:1376597385
Name:SPECTRUM HEALTH SAINT MARYS SHARED TECHNOLOGY SERVICES INC
Entity Type:Organization
Organization Name:SPECTRUM HEALTH SAINT MARYS SHARED TECHNOLOGY SERVICES INC
Other - Org Name:PET MEDICAL IMAGING & PET MEDICAL IMAGING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP AMBULATORY SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHIRCOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-391-2796
Mailing Address - Street 1:3264 NORTH EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-391-6002
Mailing Address - Fax:
Practice Address - Street 1:3264 NORTH EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-391-6002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P02650Medicare ID - Type Unspecified