Healthcare Provider Details

I. General information

NPI: 1720530405
Provider Name (Legal Business Name): GRAND RAPIDS SURGICAL SUITES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 E PARIS AVE SE SUITE 105
GRAND RAPIDS MI
49546-2459
US

IV. Provider business mailing address

2505 E PARIS AVE SE SUITE 105
GRAND RAPIDS MI
49546-2459
US

V. Phone/Fax

Practice location:
  • Phone: 616-551-3149
  • Fax: 616-551-3869
Mailing address:
  • Phone: 616-551-3149
  • Fax: 616-551-3869

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: JONATHAN BAILEY
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 203-609-1168