Basic Information
| Provider Information | |||||||||
| NPI: | 1104952332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERONTOLOGY NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 CHERRY ST SE | ||||||||
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| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566135 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 E BELTLINE AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495255848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARTWIG | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 6164566135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 1041C0700X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 251B00000X | MI | N | Agencies | Case Management | 261QA0600X | MI | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 2084P0805X | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
No ID Information.