Basic Information
| Provider Information | |||||||||
| NPI: | 1699119339 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND RIVER PHYSICAL MEDICINE PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39915 GRAND RIVER AVE | ||||||||
| Address2: | SUITE # 750 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483752153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484767775 | ||||||||
| FaxNumber: | 2489874972 | ||||||||
| Practice Location | |||||||||
| Address1: | 39915 GRAND RIVER AVE | ||||||||
| Address2: | SUITE # 750 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483752153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484767775 | ||||||||
| FaxNumber: | 2489874972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2013 | ||||||||
| LastUpdateDate: | 06/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | STANLEY | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2484767775 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | SS008515 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 363LA2200X | 4704268297 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 2083X0100X | 5101008610 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.