Provider Demographics
NPI:1619028412
Name:INTERNAL MEDICINE OF WEST MICHIGAN PLLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE OF WEST MICHIGAN PLLC
Other - Org Name:DR'S MARVIN, GANS AND ROSLANIEC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSLANIEC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-285-9090
Mailing Address - Street 1:3200 EAGLE PARK DR NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7057
Mailing Address - Country:US
Mailing Address - Phone:616-285-9090
Mailing Address - Fax:616-285-7947
Practice Address - Street 1:3200 EAGLE PARK DR NE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7057
Practice Address - Country:US
Practice Address - Phone:616-285-9090
Practice Address - Fax:616-285-7947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG02811OtherBLUE CROSS GROUP NUMBER