Provider Demographics
NPI:1649757071
Name:ST. LUKES PRIMARY CARE
Entity Type:Organization
Organization Name:ST. LUKES PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SITE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:616-227-4316
Mailing Address - Street 1:5300 PATTERSON AVE SE STE 1-D
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-5663
Mailing Address - Country:US
Mailing Address - Phone:616-227-4316
Mailing Address - Fax:616-227-4632
Practice Address - Street 1:5300 PATTERSON AVE SE STE 1-D
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512
Practice Address - Country:US
Practice Address - Phone:616-227-4316
Practice Address - Fax:616-227-4632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI003005701Medicaid