Provider Demographics
NPI:1932227915
Name:WESTERN MICHIGAN PEDIATRICS, PC
Entity Type:Organization
Organization Name:WESTERN MICHIGAN PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:VAN ZEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-949-6112
Mailing Address - Street 1:721 KENMOOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-949-6112
Mailing Address - Fax:616-949-8530
Practice Address - Street 1:710 KENMOOR AVE SE
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2379
Practice Address - Country:US
Practice Address - Phone:616-949-6112
Practice Address - Fax:616-949-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16244OtherBCBS OF MICHIGAN PIN