Provider Demographics
NPI:1699119339
Name:GRAND RIVER PHYSICAL MEDICINE PLC
Entity type:Organization
Organization Name:GRAND RIVER PHYSICAL MEDICINE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-476-7775
Mailing Address - Street 1:39915 GRAND RIVER AVE
Mailing Address - Street 2:SUITE # 750
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2153
Mailing Address - Country:US
Mailing Address - Phone:248-476-7775
Mailing Address - Fax:248-987-4972
Practice Address - Street 1:39915 GRAND RIVER AVE
Practice Address - Street 2:SUITE # 750
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2153
Practice Address - Country:US
Practice Address - Phone:248-476-7775
Practice Address - Fax:248-987-4972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISS008515111N00000X
MI51010086102083X0100X
MI4704268297363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty