Healthcare Provider Details

I. General information

NPI: 1306018684
Provider Name (Legal Business Name): MICHIGAN MEDICAL PATIENT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2026
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-459-8338
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT HARRING
Title or Position: CFO
Credential:
Phone: 616-974-4889