Provider Demographics
NPI:1760654602
Name:GRAND RAPIDS PLASTIC SURGERY PLC
Entity Type:Organization
Organization Name:GRAND RAPIDS PLASTIC SURGERY PLC
Other - Org Name:CENTRE FOR PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:FEWLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-454-1256
Mailing Address - Street 1:2060 EAST PARIS AVE SE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-454-1256
Mailing Address - Fax:616-454-0308
Practice Address - Street 1:2060 EAST PARIS AVE SE
Practice Address - Street 2:SUITE 150
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-454-1256
Practice Address - Fax:616-454-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D11002OtherBCBS
MIB0001OtherBCN
MI0D11002OtherBCBS