Healthcare Provider Details

I. General information

NPI: 1164680294
Provider Name (Legal Business Name): MICHIGAN MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 E BELTLINE CT NE
GRAND RAPIDS MI
49525-9480
US

IV. Provider business mailing address

4085 BURTON ST SE SUITE 200
GRAND RAPIDS MI
49546-2444
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-9104
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5101016694
License Number StateMI

VIII. Authorized Official

Name: SCOTT HARRING
Title or Position: CFO
Credential: CFO
Phone: 616-974-4470