Provider Demographics
NPI:1295899110
Name:MICHIGAN MEDICAL, PC.
Entity type:Organization
Organization Name:MICHIGAN MEDICAL, PC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE AND REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREVENGOED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-974-4889
Mailing Address - Street 1:4085 BURTON ST SE
Mailing Address - Street 2:STE. 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2444
Mailing Address - Country:US
Mailing Address - Phone:616-974-4889
Mailing Address - Fax:
Practice Address - Street 1:3362 LINCOLN RD. M40
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419
Practice Address - Country:US
Practice Address - Phone:269-751-5189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN MEDICAL PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-22
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M31990Medicare ID - Type Unspecified