Basic Information
Provider Information | |||||||||
NPI: | 1720375157 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEART OF THE CITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 540 CHERRY ST SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495034748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6167762212 | ||||||||
FaxNumber: | 6167762120 | ||||||||
Practice Location | |||||||||
Address1: | 100 CHERRY ST SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 49503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6167762120 | ||||||||
FaxNumber: | 6167762122 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2011 | ||||||||
LastUpdateDate: | 07/06/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SHEA | ||||||||
AuthorizedOfficialFirstName: | CHRIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXCUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6167762120 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CHERRY STREET HEALTH SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TC0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 122300000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 2084N0600X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.