Basic Information
| Provider Information | |||||||||
| NPI: | 1962494120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPECTRUM HEALTH HOSPITALS | ||||||||
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| OtherOrganizationName: | DEVOS CHILDRENS HOSPITAL END STAGE RENAL DISEASE | ||||||||
| 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: | 35 MICHIGAN ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163919000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | WELDAY | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6163912525 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 410040 | MI | N | Ambulatory Health Care Facilities | Clinic/Center | 261QE0700X | 410040 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 4695800 | 05 | MI | MEDICAID |