Provider Demographics
NPI:1417681453
Name:SPECTRUM HEALTH PRIMARY CARE PARTNERS
Entity Type:Organization
Organization Name:SPECTRUM HEALTH PRIMARY CARE PARTNERS
Other - Org Name:SPECTRUM HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-486-6630
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3195 KNIGHT WAY SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4406
Practice Address - Country:US
Practice Address - Phone:616-391-7849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-14
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty