Basic Information
| Provider Information | |||||||||
| NPI: | 1063710689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA MEDICAL CONSULTANTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163644200 | ||||||||
| FaxNumber: | 6163647347 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163644200 | ||||||||
| FaxNumber: | 6163647347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2011 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | VANDAM | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6162843100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0D10783 | 01 | MI | BCBS GRP PIN - CRNAS | OTHER | 0D10782 | 01 | MI | BCBS GRP PIN - DOCS | OTHER |