Provider Demographics
NPI:1639382211
Name:WEST MICHIGAN FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:WEST MICHIGAN FAMILY PRACTICE, PC
Other - Org Name:ADA VILLAGE MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:D.O.
Authorized Official - Prefix:
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAWRENCE-FRIEDL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-954-0402
Mailing Address - Street 1:877 FOREST HILLS
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2380
Mailing Address - Country:US
Mailing Address - Phone:616-954-0402
Mailing Address - Fax:616-954-0404
Practice Address - Street 1:877 FOREST HILL AVE SE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2380
Practice Address - Country:US
Practice Address - Phone:616-954-0402
Practice Address - Fax:616-954-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010305207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1639382211Medicaid
MIDH2054OtherRR MEDICARE
MI0D12216OtherBCBS
MI1639382211Medicaid