Healthcare Provider Details

I. General information

NPI: 1497860795
Provider Name (Legal Business Name): MI STREET ORTHOPEDIC SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MICHIGAN ST NE SUITE 200
GRAND RAPIDS MI
49503-2026
US

IV. Provider business mailing address

1300 MICHIGAN ST NE SUITE 200
GRAND RAPIDS MI
49503-2026
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-9515
  • Fax: 616-774-7116
Mailing address:
  • Phone: 616-774-9515
  • Fax: 616-774-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LORI E LUMLEY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 616-774-9515