Provider Demographics
NPI:1417154477
Name:ST MARY'S HLTH SVCS
Entity Type:Organization
Organization Name:ST MARY'S HLTH SVCS
Other - Org Name:HEARTSIDE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCCORKLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:616-913-1808
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 1A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-913-1808
Mailing Address - Fax:
Practice Address - Street 1:359 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4537
Practice Address - Country:US
Practice Address - Phone:616-643-3800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)