Healthcare Provider Details

I. General information

NPI: 1497706840
Provider Name (Legal Business Name): METRO HEALTH BASIC CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 CLYDE PARK AVE SW
WYOMING MI
49509-9525
US

IV. Provider business mailing address

1925 BRETON RD SE SUITE 201
GRAND RAPIDS MI
49506-4810
US

V. Phone/Fax

Practice location:
  • Phone: 616-531-7769
  • Fax: 616-531-7845
Mailing address:
  • Phone: 616-252-4765
  • Fax: 616-252-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL FAAS
Title or Position: CEO
Credential:
Phone: 616-252-7200