MEDICARE: COURTNEY ANN VANDEWEGE ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1750393773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY ANN VANDEWEGE ATC

Provider Business Mailing Address
First Line	:	5480 PARK AVE
Second Line	:
City	:	HUDSONVILLE
State	:	MI
Zip	:	49426-1245
Country	:	US
Telephone Number	:	616-322-3145
Fax Number	:

Provider Business Practice Location Address
First Line	:	2211 LAKE DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-3026
Country	:	US
Telephone Number	:	616-322-3145
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	07/08/2007

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