Provider Demographics
NPI:1578691432
Name:GERONTOLOGY NETWORK
Entity Type:Organization
Organization Name:GERONTOLOGY NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTWIG
Authorized Official - Suffix:IV
Authorized Official - Credentials:PHD
Authorized Official - Phone:616-456-6135
Mailing Address - Street 1:500 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4702
Mailing Address - Country:US
Mailing Address - Phone:616-456-6135
Mailing Address - Fax:616-771-9771
Practice Address - Street 1:4650 W US HIGHWAY 223 STE A
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-8494
Practice Address - Country:US
Practice Address - Phone:517-226-2588
Practice Address - Fax:517-226-0224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16140Medicare ID - Type UnspecifiedMD
MI0P51090Medicare PIN
MI0D16163Medicare ID - Type UnspecifiedMSW