Basic Information
| Provider Information | |||||||||
| NPI: | 1689101784 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM HEALTH HOSPITALS | ||||||||
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| OtherOrganizationName: | SPECTRUM HEALTH REHAB AND NURSING CENTER-FULLER AVENUE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166439143 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 FULLER AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495031918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164863001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2017 | ||||||||
| LastUpdateDate: | 05/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | WELDAY | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP, FINANCE SHHG | ||||||||
| AuthorizedOfficialTelephone: | 6163912525 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECTRUM HEALTH HOSPITALS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1070000195 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 624151184 | 05 | MI | MEDICAID |