Provider Demographics
NPI:1295761914
Name:TRINITY HEALTH - MICHIGAN
Entity type:Organization
Organization Name:TRINITY HEALTH - MICHIGAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:CASALOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-712-3792
Mailing Address - Street 1:360 DIVISION AVE S
Mailing Address - Street 2:STE 1C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4501
Mailing Address - Country:US
Mailing Address - Phone:616-685-1100
Mailing Address - Fax:616-685-1115
Practice Address - Street 1:360 DIVISION AVE S
Practice Address - Street 2:STE 1C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4501
Practice Address - Country:US
Practice Address - Phone:616-685-1100
Practice Address - Fax:616-685-1196
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY HEALTH - MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010057603336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042216OtherPK
MI4825128Medicaid
5281450001Medicare NSC