MEDICARE: WEST MICHIGAN CARDIOLOGY, PC

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	174400000X	Specialist	TM058656	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	060E960210	OTHER	MI	BLUE SHIELD
2	161	OTHER	MI	PRIORITY HEALTH

General Provider Information

NPI Number	:	1780770859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST MICHIGAN CARDIOLOGY, PC

Provider Business Mailing Address
First Line	:	PO BOX 150036
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49515-0036
Country	:	US
Telephone Number	:	616-456-9553
Fax Number	:	616-454-5371

Provider Business Practice Location Address
First Line	:	3210 EAGLE RUN DR NE STE 100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-7051
Country	:	US
Telephone Number	:	616-456-9553
Fax Number	:	616-454-5371

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MEGAN A TARATUTA
Credential	:
Telephone Number	:	616-456-9553

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	05/14/2024

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