Provider Demographics
NPI:1790894822
Name:GRAND RIVER SURGERY, PLLC
Entity Type:Organization
Organization Name:GRAND RIVER SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARET
Authorized Official - Middle Name:
Authorized Official - Last Name:BEANE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-532-8100
Mailing Address - Street 1:2093 HEALTH DRIVE SW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519
Mailing Address - Country:US
Mailing Address - Phone:616-532-8100
Mailing Address - Fax:616-532-8200
Practice Address - Street 1:2093 HEALTH DRIVE SW
Practice Address - Street 2:SUITE 300
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-532-8100
Practice Address - Fax:616-532-8200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014347208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty