Provider Demographics
NPI:1104931492
Name:AMBULATORY UNITED
Entity type:Organization
Organization Name:AMBULATORY UNITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-754-4691
Mailing Address - Street 1:PO BOX 2566
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-2566
Mailing Address - Country:US
Mailing Address - Phone:231-832-8555
Mailing Address - Fax:
Practice Address - Street 1:1202 W OAK ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2155
Practice Address - Country:US
Practice Address - Phone:616-754-2944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M57980Medicare ID - Type UnspecifiedGROUP NUMBER
MI0P01210Medicare ID - Type UnspecifiedGROUP NUMBER/AMBULATORY