Healthcare Provider Details

I. General information

NPI: 1184815417
Provider Name (Legal Business Name): GRAND RAPIDS PLASTIC SURGERY PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 MICHIGAN ST STE 300
GRAND RAPIDS MI
49503-5609
US

IV. Provider business mailing address

426 MICHIGAN ST STE 300
GRAND RAPIDS MI
49503-5609
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-1256
  • Fax: 616-831-2648
Mailing address:
  • Phone: 616-454-1256
  • Fax: 616-831-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateMI

VIII. Authorized Official

Name: SCOTT R BRUNDAGE
Title or Position: MEMBER
Credential: MD
Phone: 616-454-1257