Provider Demographics
NPI:1871674200
Name:RENAL ASSOCIATES OF WEST MICHIGAN PC
Entity Type:Organization
Organization Name:RENAL ASSOCIATES OF WEST MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOELKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-752-6235
Mailing Address - Street 1:330 E BELTLINE AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1267
Mailing Address - Country:US
Mailing Address - Phone:616-752-6235
Mailing Address - Fax:616-752-6324
Practice Address - Street 1:330 E BELTLINE AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1267
Practice Address - Country:US
Practice Address - Phone:616-752-6235
Practice Address - Fax:616-752-6324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1871674200Medicaid