=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720530405
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND RAPIDS SURGICAL SUITES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2016
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2505 E PARIS AVE SE SUITE 105
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-551-3149
-----------------------------------------------------
Fax | 616-551-3869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2505 E PARIS AVE SE SUITE 105
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-551-3149
-----------------------------------------------------
Fax | 616-551-3869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | JONATHAN BAILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-609-1168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------