MEDICARE: ELDER CARE OF WEST MICHIGAN PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1427514306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELDER CARE OF WEST MICHIGAN PLLC

Provider Business Mailing Address
First Line	:	4448 KOINONIA DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9332
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6785 MYERS LAKE AVE NE
Second Line	:
City	:	ROCKFORD
State	:	MI
Zip	:	49341-7416
Country	:	US
Telephone Number	:	616-366-4234
Fax Number	:	616-469-1118

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	KATHY JO UECKER
Credential	:
Telephone Number	:	269-420-9404

Provider Enumeration Date	:	02/15/2019
Last Update Date	:	05/02/2019

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