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General NPI Number Information
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NPI Number | 1386971711
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Entity Type | Organization
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Legal Business Name | PHYSICIAN'S HOME NETWORK, PLLC
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Dates
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Enumeration Date | 11/05/2009
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Last Update Date | 11/05/2009
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Provider Practice Location Address
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Address Line | 3033 ORCHARD VISTA DR SE SUITE 309
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-7077
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Country | US
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Telephone | 616-608-7403
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Fax | 616-608-7408
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Provider Business Mailing Address
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Address Line | 3033 ORCHARD VISTA DR SE SUITE 309
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-7077
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Country | US
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Telephone | 616-608-7403
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Fax | 616-608-7408
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Authorized Official
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Title or Position | CEO
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Name | KURTIS SMITKO
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Credential | MSPT
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Telephone | 616-608-7403
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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