Provider Demographics
NPI:1639334626
Name:JOHN J. POTENTE P.C.
Entity Type:Organization
Organization Name:JOHN J. POTENTE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:POTENTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-249-1800
Mailing Address - Street 1:3181 PRAIRIE ST SW
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2097
Mailing Address - Country:US
Mailing Address - Phone:616-249-1800
Mailing Address - Fax:
Practice Address - Street 1:3181 PRAIRIE ST SW
Practice Address - Street 2:SUITE 105
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2097
Practice Address - Country:US
Practice Address - Phone:616-249-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-19
Last Update Date:2008-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004828261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950D152200OtherBLUE CROSS& BLUE SHIELD
MIT66326Medicare UPIN
MIOD15220Medicare PIN