=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568632669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLERGY & ASTHMA CENTERS OF WEST MICHIGAN, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2008
-----------------------------------------------------
Last Update Date | 03/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5055 PLAINFIELD AVE NE SUITE C
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-1075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-988-8515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5055 PLAINFIELD AVE NE SUITE C
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-1075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-988-8515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | VINCENT DUBRAVEC
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 616-988-8515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 4301073903
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------