Provider Demographics
NPI:1811983000
Name:SPECTRUM HEALTH
Entity type:Organization
Organization Name:SPECTRUM HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGALS
Authorized Official - Middle Name:D
Authorized Official - Last Name:WELDAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-391-2525
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 406
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-1774
Mailing Address - Fax:616-774-7699
Practice Address - Street 1:4069 LAKE DR SE
Practice Address - Street 2:SUITE 210
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8816
Practice Address - Country:US
Practice Address - Phone:616-285-1120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRUM HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-09-22
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
MI416835261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI41034OtherBLUE CROSS
MI5170255Medicaid
MI5170255Medicaid