Healthcare Provider Details

I. General information

NPI: 1992204135
Provider Name (Legal Business Name): SPECTRUM HEALTH PRIMARY CARE PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2018
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7985 MACKINAW TRL
CADILLAC MI
49601-8111
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3681
  • Fax:
Mailing address:
  • Phone: 616-486-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: LEISA KIMBROUGH
Title or Position: SENIOR DIRECTOR
Credential:
Phone: 616-486-6579