Provider Demographics
NPI:1598845794
Name:KENTWOOD FAMILY PHYSICIANS PC
Entity Type:Organization
Organization Name:KENTWOOD FAMILY PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-281-9066
Mailing Address - Street 1:5070 CASCADE RD SE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8422
Mailing Address - Country:US
Mailing Address - Phone:616-281-9066
Mailing Address - Fax:616-281-0539
Practice Address - Street 1:5070 CASCADE RD SE
Practice Address - Street 2:SUITE 250
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8422
Practice Address - Country:US
Practice Address - Phone:616-281-9066
Practice Address - Fax:616-281-0539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P27140Medicare ID - Type UnspecifiedMEDICARE GROUP PROV NUMB