Provider Demographics
NPI:1457850802
Name:SPECTRUM HEALTH PRIMARY CARE PARTNERS
Entity Type:Organization
Organization Name:SPECTRUM HEALTH PRIMARY CARE PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE CHEIF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTENBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-486-6686
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 1:4075 32ND AVE
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426
Practice Address - Country:US
Practice Address - Phone:616-486-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRUM HEALTH PRIMARY CARE PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty