Provider Demographics
NPI:1518285022
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:SVP, FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRYWANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-486-2253
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
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 1:426 MICHIGAN ST NE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5609
Practice Address - Country:US
Practice Address - Phone:616-391-2242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRUM HEALTH PRIMARY CARE PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-07
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103T00000X
103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M74460Medicare PIN