Basic Information
| Provider Information | |||||||||
| NPI: | 1811983000 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM HEALTH | ||||||||
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| OtherOrganizationName: | SPECTRUM HEALTH- LAKE DRIVE SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC 406 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163911774 | ||||||||
| FaxNumber: | 6167747699 | ||||||||
| Practice Location | |||||||||
| Address1: | 4069 LAKE DR SE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495468816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162851120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | WELDAY | ||||||||
| AuthorizedOfficialFirstName: | DOUGALS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6163912525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECTRUM HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QA1903X | 416835 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 41034 | 01 | MI | BLUE CROSS | OTHER | 5170255 | 05 | MI | MEDICAID |