Healthcare Provider Details

I. General information

NPI: 1902002264
Provider Name (Legal Business Name): ST MARYS HLTH SVCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 CHERRY ST SE STE 306
GRAND RAPIDS MI
49503-4607
US

IV. Provider business mailing address

245 STATE ST SE STE 1A
GRAND RAPIDS MI
49503-4328
US

V. Phone/Fax

Practice location:
  • Phone: 616-913-8200
  • Fax:
Mailing address:
  • Phone: 616-913-1808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: PHILIP H MCCORKLE JR.
Title or Position: CEO
Credential:
Phone: 616-913-1808