Healthcare Provider Details

I. General information

NPI: 1780770859
Provider Name (Legal Business Name): WEST MICHIGAN CARDIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 EAGLE RUN DR NE STE 100
GRAND RAPIDS MI
49525-7051
US

IV. Provider business mailing address

PO BOX 150036
GRAND RAPIDS MI
49515-0036
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-9553
  • Fax: 616-454-5371
Mailing address:
  • Phone: 616-456-9553
  • Fax: 616-454-5371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberTM058656
License Number StateMI

VIII. Authorized Official

Name: MEGAN A TARATUTA
Title or Position: PRACTICE MANAGER
Credential:
Phone: 616-456-9553