Healthcare Provider Details

I. General information

NPI: 1679701601
Provider Name (Legal Business Name): GRAND RAPIDS MEDICAL EDUCATION AND RESEARCH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BARCLAY AVE NE SUITE 304
GRAND RAPIDS MI
49503-2556
US

IV. Provider business mailing address

330 BARCLAY AVE NE SUITE 304
GRAND RAPIDS MI
49503-2556
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-2160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number5101018314
License Number StateMI

VIII. Authorized Official

Name: DR. PETER ENGELMAN
Title or Position: RESIDENT
Credential: D.O.
Phone: 816-392-8112