Healthcare Provider Details

I. General information

NPI: 1891990701
Provider Name (Legal Business Name): MEGHAN MARIE SUMMEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGHAN MARIE BULGER PA-C

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 BRETON RD SE
GRAND RAPIDS MI
49506-4810
US

IV. Provider business mailing address

985 GEZON PKWY SW ATTN: TERESA MCNALLY
WYOMING MI
49509-9563
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-4100
  • Fax: 616-252-4953
Mailing address:
  • Phone: 616-252-4655
  • Fax: 616-252-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005000
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: