Provider Demographics
NPI:1902002272
Name:TRINITY HEALTH - MICHIGAN
Entity Type:Organization
Organization Name:TRINITY HEALTH - MICHIGAN
Other - Org Name:HEARTSIDE HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:H
Authorized Official - Last Name:MCCORKLE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:616-685-1808
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:STE 1A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-685-8050
Mailing Address - Fax:616-685-1818
Practice Address - Street 1:359 S DIVISION AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-685-3800
Practice Address - Fax:616-235-0913
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY HEALTH - MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-25
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P32930Medicare PIN