Healthcare Provider Details

I. General information

NPI: 1568440139
Provider Name (Legal Business Name): SPECTRUM HEALTH KENT COMMUNITY CAMPUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 FULLER AVE NE MC 160
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

750 FULLER AVE NE MC 160
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-486-2411
  • Fax: 616-486-2419
Mailing address:
  • Phone: 616-643-9083
  • Fax: 616-643-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number410090
License Number StateMI

VIII. Authorized Official

Name: MR. LAWRENCE J OBERST
Title or Position: SHCC/DIRECTOR OF FINANCE
Credential:
Phone: 616-486-2405