Provider Demographics
NPI:1568440139
Name:SPECTRUM HEALTH KENT COMMUNITY CAMPUS
Entity Type:Organization
Organization Name:SPECTRUM HEALTH KENT COMMUNITY CAMPUS
Other - Org Name:SPECTRUM HEALTH SPECIAL CARE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SHCC/DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:OBERST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-486-2405
Mailing Address - Street 1:750 FULLER AVE NE
Mailing Address - Street 2:MC 160
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-643-9083
Mailing Address - Fax:616-643-9060
Practice Address - Street 1:750 FULLER AVE NE
Practice Address - Street 2:MC 160
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-486-2411
Practice Address - Fax:616-486-2419
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRUM HEALTH CONTINUING CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-04
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI410090282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI405170970Medicaid
MI00322OtherBCBS
MI405170970Medicaid