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General NPI Number Information
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NPI Number | 1336504760
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Entity Type | Organization
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Legal Business Name | GRAND RAPIDS THORACIC SURGERY, PLLC
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Dates
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Enumeration Date | 12/30/2015
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Last Update Date | 12/30/2015
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Provider Practice Location Address
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Address Line | 4500 CASCADE RD SE SUITE 210
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3665
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Country | US
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Telephone | 616-259-7341
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Fax | 616-259-7642
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Provider Business Mailing Address
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Address Line | 4500 CASCADE RD SE SUITE 210
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-3665
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Country | US
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Telephone | 616-259-7341
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Fax | 616-259-7642
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Authorized Official
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Title or Position | OWNER
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Name | LOURENS J. WILLEKES II
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Credential | M.D.
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Telephone | 616-259-7341
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208G00000X
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Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
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License Number | 4301104138
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License Number State | MI
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