Provider Demographics
NPI:1750443511
Name:MICHIGAN MEDICAL, PC.
Entity Type:Organization
Organization Name:MICHIGAN MEDICAL, PC.
Other - Org Name:GRAND RAPIDS OBGYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE AND REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREVENGOED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-974-4889
Mailing Address - Street 1:4085 BURTON ST SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2444
Mailing Address - Country:US
Mailing Address - Phone:616-974-4889
Mailing Address - Fax:616-974-4582
Practice Address - Street 1:3800 LAKE MICHIGAN DR NW
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-4583
Practice Address - Country:US
Practice Address - Phone:616-453-8225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M14680Medicare ID - Type Unspecified