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NPI Code Detail

MEDICARE: MISS RUTH JEAN VANDENBERG P.A.-C.

MEDICARE: MISS RUTH JEAN VANDENBERG P.A.-C.
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
1363A00000XPhysician Assistant5601004042MI

General Provider Information

NPI Number : 1679783120
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS RUTH JEAN VANDENBERG P.A.-C.
Provider Business Mailing Address
First Line : PO BOX 2564
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49501-2564
Country : US
Telephone Number : 646-776-0814
Fax Number : 616-776-9956
Provider Business Practice Location Address
First Line : 1330 PLAINFIELD AVE NE
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49505-4913
Country : US
Telephone Number : 616-776-0814
Fax Number : 616-776-9956
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2007
Last Update Date : 07/08/2007

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Directions to “ MISS RUTH JEAN VANDENBERG P.A.-C.” Practice Location

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