Provider Demographics
NPI:1104170661
Name:INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN
Entity type:Organization
Organization Name:INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAWLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-323-3227
Mailing Address - Street 1:655 KENMOOR AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-363-7690
Mailing Address - Fax:616-942-8917
Practice Address - Street 1:655 KENMOOR AVE SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-363-7690
Practice Address - Fax:616-942-8917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071009207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1467490953Medicaid