Healthcare Provider Details

I. General information

NPI: 1932330636
Provider Name (Legal Business Name): MICHIGAN MEDICAL PATIENT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E PARIS AVE SE
GRAND RAPIDS MI
49546-8367
US

IV. Provider business mailing address

4085 BURTON ST SE SUITE 200
GRAND RAPIDS MI
49546-2444
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number4301078284
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301078284
License Number StateMI

VIII. Authorized Official

Name: SCOTT HARRING
Title or Position: CFO
Credential:
Phone: 616-974-4889