Provider Demographics
NPI:1780642355
Name:GRAND RAPIDS ADDICTION MEDICINE SPECIALISTS PC
Entity Type:Organization
Organization Name:GRAND RAPIDS ADDICTION MEDICINE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KHAN
Authorized Official - Middle Name:JAVAN
Authorized Official - Last Name:NEDD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-954-0600
Mailing Address - Street 1:PO BOX 1682
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1682
Mailing Address - Country:US
Mailing Address - Phone:616-954-0600
Mailing Address - Fax:616-954-1675
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:SUITE 305
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-954-0600
Practice Address - Fax:616-954-1675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P14500Medicare PIN