Basic Information
| Provider Information | |||||||||
| NPI: | 1578691432 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GERONTOLOGY NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566135 | ||||||||
| FaxNumber: | 6167719771 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 W US HIGHWAY 223 STE A | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492218494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172262588 | ||||||||
| FaxNumber: | 5172260224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 05/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | HARTWIG | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6164566135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | IV | ||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 2084P0805X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
No ID Information.