Healthcare Provider Details

I. General information

NPI: 1679839146
Provider Name (Legal Business Name): ORTHOPAEDIC ASSOCIATES OF GRAND RAPIDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 68TH ST SE
GRAND RAPIDS MI
49548-6980
US

IV. Provider business mailing address

PO BOX 30516 DEPT 6063
LANSING MI
48909-8016
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-7101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCP01303
License Number StateMI

VIII. Authorized Official

Name: PATRICK REID
Title or Position: CEO
Credential:
Phone: 616-459-7101