=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376862151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANTAGE HEALTH/SAINT MARY'S MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2010
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 STATE ST SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-685-8050
-----------------------------------------------------
Fax | 616-685-1850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776974
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-6974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-494-5797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP FINANCES GR
-----------------------------------------------------
Name | DANIEL GREEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-685-6709
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------