Basic Information
| Provider Information | |||||||||
| NPI: | 1710378377 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAWM VASCULAR ACCESS, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | RAWM VASCULAR ACCESS CENTER, PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 330 E BELTLINE NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495061208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167526235 | ||||||||
| FaxNumber: | 6167526324 | ||||||||
| Practice Location | |||||||||
| Address1: | 1540 36TH STREET. SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165323072 | ||||||||
| FaxNumber: | 6165324078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2015 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UNRUH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 6165323072 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1104036532 | 05 | MI | MEDICAID |