Healthcare Provider Details

I. General information

NPI: 1477516110
Provider Name (Legal Business Name): PEDIATRIC SURGEONS OF WEST MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY NE SUITE 202
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

330 BARCLAY NE SUITE 202
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-1722
  • Fax: 616-458-0061
Mailing address:
  • Phone: 616-458-1722
  • Fax: 616-458-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JENNIFER L JAMULA
Title or Position: PRACTICE MANAGER
Credential:
Phone: 616-458-1722