Provider Demographics
NPI:1629002852
Name:HOLLAND FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:HOLLAND FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DERKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-392-2361
Mailing Address - Street 1:601 MICHIGAN AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4951
Mailing Address - Country:US
Mailing Address - Phone:616-392-2361
Mailing Address - Fax:616-392-2364
Practice Address - Street 1:601 MICHIGAN AVE STE 104
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4951
Practice Address - Country:US
Practice Address - Phone:616-392-2361
Practice Address - Fax:616-392-2364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G04700Medicare PIN