Healthcare Provider Details

I. General information

NPI: 1386971711
Provider Name (Legal Business Name): PHYSICIAN'S HOME NETWORK, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 ORCHARD VISTA DR SE SUITE 309
GRAND RAPIDS MI
49546-7077
US

IV. Provider business mailing address

3033 ORCHARD VISTA DR SE SUITE 309
GRAND RAPIDS MI
49546-7077
US

V. Phone/Fax

Practice location:
  • Phone: 616-608-7403
  • Fax: 616-608-7408
Mailing address:
  • Phone: 616-608-7403
  • Fax: 616-608-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KURTIS SMITKO
Title or Position: CEO
Credential: MSPT
Phone: 616-608-7403