Provider Demographics
NPI:1508055294
Name:ADVANTAGE HEALTH CONVENIENT CARE PLLC
Entity Type:Organization
Organization Name:ADVANTAGE HEALTH CONVENIENT CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CMO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-913-1800
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 326
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-913-1800
Mailing Address - Fax:
Practice Address - Street 1:6370 LAKE MICHIGAN DR
Practice Address - Street 2:STE 100
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9226
Practice Address - Country:US
Practice Address - Phone:616-895-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P51510Medicare PIN