Basic Information
| Provider Information | |||||||||
| NPI: | 1053550590 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARY FREE BED REHABILITATION HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 WEALTHY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495035247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162420300 | ||||||||
| FaxNumber: | 6162420438 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 WEALTHY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495035247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162420300 | ||||||||
| FaxNumber: | 6162420438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2009 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | PODVIN | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6168408676 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 410070 | MI | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | OM95520 | 01 | MI | MEDICARE PART B | OTHER |