Provider Demographics
NPI:1215921036
Name:GRAND HAVEN PATHOLOGY, PC
Entity type:Organization
Organization Name:GRAND HAVEN PATHOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:AARDEMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-847-5200
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1309 SHELDON RD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2404
Practice Address - Country:US
Practice Address - Phone:616-847-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI38349342207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI220G010300OtherBLUE CROSS
MI0M91460Medicare ID - Type Unspecified