Provider Demographics
NPI:1497860795
Name:MI STREET ORTHOPEDIC SPECIALISTS PC
Entity Type:Organization
Organization Name:MI STREET ORTHOPEDIC SPECIALISTS PC
Other - Org Name:BEREZA & LOVELL ORTHOPEDICS, P.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUMLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-774-9515
Mailing Address - Street 1:1300 MICHIGAN ST NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2026
Mailing Address - Country:US
Mailing Address - Phone:616-774-9515
Mailing Address - Fax:616-774-7116
Practice Address - Street 1:1300 MICHIGAN ST NE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2026
Practice Address - Country:US
Practice Address - Phone:616-774-9515
Practice Address - Fax:616-774-7116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5965940001Medicare NSC
MI0N96810Medicare PIN