Provider Demographics
NPI:1588821433
Name:WEST MICHIGAN ADDICTION CONSULTANTS, PC
Entity type:Organization
Organization Name:WEST MICHIGAN ADDICTION CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-365-8800
Mailing Address - Street 1:3001 FULLER AVE NE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3247
Mailing Address - Country:US
Mailing Address - Phone:616-365-8800
Mailing Address - Fax:616-365-7979
Practice Address - Street 1:3001 FULLER AVE NE
Practice Address - Street 2:SUITE 1
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-3247
Practice Address - Country:US
Practice Address - Phone:616-365-8800
Practice Address - Fax:616-365-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI100005207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0504118411OtherBCBS