Healthcare Provider Details

I. General information

NPI: 1164296380
Provider Name (Legal Business Name): WEST MICHIGAN CARDIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 EAGLE RUN DR NE
GRAND RAPIDS MI
49525-7051
US

IV. Provider business mailing address

3210 EAGLE RUN DR NE
GRAND RAPIDS MI
49525-7051
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-9553
  • Fax: 616-454-5371
Mailing address:
  • Phone: 616-456-9553
  • Fax: 616-454-5371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0404X
TaxonomyCardiac Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WC3500X
TaxonomyCardiac Rehabilitation Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: TEJINDER S. MANDER
Title or Position: PRACTICE OWNER
Credential: MD
Phone: 616-456-9553