Provider Demographics
NPI:1932741907
Name:ADVANCED MEDICAL GROUP
Entity Type:Organization
Organization Name:ADVANCED MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EOVALDI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-669-6702
Mailing Address - Street 1:3360 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1420
Mailing Address - Country:US
Mailing Address - Phone:616-669-6702
Mailing Address - Fax:616-797-4025
Practice Address - Street 1:3360 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1420
Practice Address - Country:US
Practice Address - Phone:616-669-6702
Practice Address - Fax:616-797-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5315213606OtherMI CONTROLLED SUBSTANCE
5101019505OtherMI OSTEOPATHIC MEDICAL LICENSE
1902155690OtherNPI TYPE 1
14554401OtherCAQH#