=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619028412
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNAL MEDICINE OF WEST MICHIGAN PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 EAGLE PARK DR NE SUITE 102
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-7057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-285-9090
-----------------------------------------------------
Fax | 616-285-7947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 EAGLE PARK DR NE SUITE 102
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-7057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-285-9090
-----------------------------------------------------
Fax | 616-285-7947
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | ELIZABETH A KOZAK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 616-285-9090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------