MEDICARE: HEART AND WELLNESS INSTITUTE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	4301080691	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	DG1222	OTHER		RR / RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1194935387	OTHER		UNITED HEALTHCARE
4	060D120890	OTHER	MI	BLUE CROSS BLUE SHIELD
5	0P46910	OTHER		COFINITY / PPOM

General Provider Information

NPI Number	:	1194935387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART AND WELLNESS INSTITUTE

Provider Business Mailing Address
First Line	:	5043 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3724
Country	:	US
Telephone Number	:	616-719-5939
Fax Number	:	616-719-5933

Provider Business Practice Location Address
First Line	:	5043 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3724
Country	:	US
Telephone Number	:	616-719-5939
Fax Number	:	616-719-5933

Authorized Official
Title or Position	:	ADMIN / OFFICE MGR
Name	:	MRS. BARBARA ANNETTE WARREN
Credential	:	MSM
Telephone Number	:	616-719-5939

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	04/12/2011

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Directions to “HEART AND WELLNESS INSTITUTE ” Practice Location

Language	Start Address	Practice Location

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