Healthcare Provider Details

I. General information

NPI: 1174835102
Provider Name (Legal Business Name): SPECTRUM HEALTH PRIMARY CARE PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2010
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4085 BURTON ST SE SUITE 312
GRAND RAPIDS MI
49546-2444
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-284-8842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PAULINE KRYWANSKI
Title or Position: CFO
Credential:
Phone: 616-486-2253