Healthcare Provider Details

I. General information

NPI: 1932768058
Provider Name (Legal Business Name): SPARTAN RADIOLOGY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-7339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. RITA WESTPHAL
Title or Position: BOARD MEMBER
Credential:
Phone: 616-363-7339