Provider Demographics
NPI:1184898454
Name:PETER S VASIU DO PC
Entity type:Organization
Organization Name:PETER S VASIU DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-281-7000
Mailing Address - Street 1:2591 44TH ST SE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9094
Mailing Address - Country:US
Mailing Address - Phone:616-281-7000
Mailing Address - Fax:
Practice Address - Street 1:2591 44TH ST SE
Practice Address - Street 2:SUITE 103
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-9094
Practice Address - Country:US
Practice Address - Phone:616-281-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012366207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2054102165OtherBLUE CROSS BLUE SHIELD
MI4521418Medicaid
MI2054102165OtherBLUE CROSS BLUE SHIELD
MI4521418Medicaid