Healthcare Provider Details

I. General information

NPI: 1831293190
Provider Name (Legal Business Name): WESTERN MICHIGAN PEDIATRIC CARDIOLOGY ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY NE #201
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

330 BARCLAY NE #201
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-8247
  • Fax: 616-459-0034
Mailing address:
  • Phone: 616-459-8247
  • Fax: 616-459-0034

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: MRS. CYNDI L MANSFIELD
Title or Position: OFFICE SUPERVISOR
Credential:
Phone: 616-459-8247