Provider Demographics
NPI:1609810985
Name:GERIATRIC & EXTENDED REHABILITATION MEDICINE LLC
Entity Type:Organization
Organization Name:GERIATRIC & EXTENDED REHABILITATION MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:EZRA
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-844-4067
Mailing Address - Street 1:1159 S HARBOR
Mailing Address - Street 2:C4
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1777
Mailing Address - Country:US
Mailing Address - Phone:616-844-4067
Mailing Address - Fax:616-844-4067
Practice Address - Street 1:1159 S HARBOR DR
Practice Address - Street 2:SUITE C-4
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1777
Practice Address - Country:US
Practice Address - Phone:616-844-4067
Practice Address - Fax:616-844-4067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009705207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N97730Medicare PIN
0N97720Medicare PIN