Provider Demographics
NPI:1912195876
Name:WKQ INC DBA NORTHSIDE IMMEDIATE CARE CENTER
Entity Type:Organization
Organization Name:WKQ INC DBA NORTHSIDE IMMEDIATE CARE CENTER
Other - Org Name:NORTHSIDE IMMEDIATE CARE URGENT CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERWIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRASMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-744-4743
Mailing Address - Street 1:420 WHITEHALL RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:N MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-3299
Mailing Address - Country:US
Mailing Address - Phone:231-744-4743
Mailing Address - Fax:231-744-4745
Practice Address - Street 1:420 WHITEHALL RD
Practice Address - Street 2:SUITE 4
Practice Address - City:N MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3299
Practice Address - Country:US
Practice Address - Phone:231-744-4743
Practice Address - Fax:231-744-4745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0F16019OtherBCBS MI
MI0F11097OtherBCN UCC
MI0F16019Medicare UPIN