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General NPI Number Information
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NPI Number | 1649757071
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Entity Type | Organization
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Legal Business Name | ST. LUKES PRIMARY CARE
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Dates
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Enumeration Date | 07/27/2018
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Last Update Date | 07/27/2018
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Provider Practice Location Address
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Address Line | 5300 PATTERSON AVE SE STE 1-D
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City | GRAND RAPIDS
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State | MI
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Zip | 49512
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Country | US
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Telephone | 616-227-4316
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Fax | 616-227-4632
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Provider Business Mailing Address
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Address Line | 5300 PATTERSON AVE SE STE 1-D
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City | GRAND RAPIDS
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State | MI
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Zip | 49512-5663
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Country | US
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Telephone | 616-227-4316
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Fax | 616-227-4632
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Authorized Official
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Title or Position | SITE MANAGER
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Name | DARLENE MILLS
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Credential | RN
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Telephone | 616-227-4316
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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