Basic Information
Provider Information | |||||||||
NPI: | 1467801894 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARY FREE BED REHABILITATION HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 235 WEALTHY ST SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495035247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6168408000 | ||||||||
FaxNumber: | 6168409718 | ||||||||
Practice Location | |||||||||
Address1: | 235 WEALTHY ST SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495035247 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6168408000 | ||||||||
FaxNumber: | 6168409718 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2016 | ||||||||
LastUpdateDate: | 06/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DENEFF | ||||||||
AuthorizedOfficialFirstName: | RANDALL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 6168408317 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283XC2000X |   |   | Y |   | Hospitals | Rehabilitation Hospital | Children |
ID Information
ID | Type | State | Issuer | Description | 233026 | 01 | MI | MEDICARE ID-TYPE UNSPECIFIED | OTHER | 3996 | 01 | MI | PRIORITY HEALTH | OTHER | 101556008 | 05 | MI |   | MEDICAID |