Provider Demographics
NPI:1801101985
Name:FAMILY PRACTICE ASSOCIATES OF WEST MICHIGAN P.C.
Entity type:Organization
Organization Name:FAMILY PRACTICE ASSOCIATES OF WEST MICHIGAN P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:SETH
Authorized Official - Last Name:VANWORMER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-975-2550
Mailing Address - Street 1:6735 CASCADE RD SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6887
Mailing Address - Country:US
Mailing Address - Phone:616-975-2550
Mailing Address - Fax:616-975-2555
Practice Address - Street 1:6735 CASCADE RD SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6887
Practice Address - Country:US
Practice Address - Phone:616-975-2550
Practice Address - Fax:616-975-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI 5101009001261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION13300OtherMEDICARE PTAN
MION13300OtherMEDICARE PTAN