Healthcare Provider Details

I. General information

NPI: 1245572007
Provider Name (Legal Business Name): PENNANT PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MIDTOWNE ST NE SUITE 310
GRAND RAPIDS MI
49503-5729
US

IV. Provider business mailing address

2122 HEALTH DR SW SUITE 230
WYOMING MI
49519-9698
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-4765
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: FRANK E BELSITO
Title or Position: CMO
Credential: DO
Phone: 616-252-5211