Healthcare Provider Details

I. General information

NPI: 1295899110
Provider Name (Legal Business Name): MICHIGAN MEDICAL, PC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3362 LINCOLN RD. M40
HAMILTON MI
49419
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 269-751-5189
  • Fax:
Mailing address:
  • Phone: 616-974-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DANIEL GREVENGOED
Title or Position: VP OF FINANCE AND REIMBURSEMENT
Credential:
Phone: 616-974-4889