Healthcare Provider Details

I. General information

NPI: 1578691432
Provider Name (Legal Business Name): GERONTOLOGY NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W US HIGHWAY 223 STE A
ADRIAN MI
49221-8494
US

IV. Provider business mailing address

500 CHERRY ST SE
GRAND RAPIDS MI
49503-4702
US

V. Phone/Fax

Practice location:
  • Phone: 517-226-2588
  • Fax: 517-226-0224
Mailing address:
  • Phone: 616-456-6135
  • Fax: 616-771-9771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS HARTWIG IV
Title or Position: PRESIDENT
Credential: PHD
Phone: 616-456-6135