Healthcare Provider Details

I. General information

NPI: 1649306879
Provider Name (Legal Business Name): GERONTOLOGY NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 CHERRY ST SE
GRAND RAPIDS MI
49503-4702
US

IV. Provider business mailing address

516 CHERRY ST SE
GRAND RAPIDS MI
49503-4702
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6135
  • Fax:
Mailing address:
  • Phone: 616-456-6135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: THOMAS A HARTWIG
Title or Position: PRESIDENT CEO
Credential: PHD
Phone: 616-456-6135