Healthcare Provider Details

I. General information

NPI: 1003515008
Provider Name (Legal Business Name): ADVANTAGE HEALTH SAINT MARY'S MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 64TH ST SW STE 2700
BYRON CENTER MI
49315-7978
US

IV. Provider business mailing address

PO BOX 776974
CHICAGO IL
60677-6974
US

V. Phone/Fax

Practice location:
  • Phone: 616-465-5910
  • Fax: 616-465-5911
Mailing address:
  • Phone: 800-494-5797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DANIEL GREEN
Title or Position: VP FINANCE
Credential:
Phone: 616-685-6709