Provider Demographics
NPI:1144534520
Name:SPECTRUM HEALTH KELSEY
Entity type:Organization
Organization Name:SPECTRUM HEALTH KELSEY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-225-6310
Mailing Address - Street 1:PO BOX 3567
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-3567
Mailing Address - Country:US
Mailing Address - Phone:231-832-8555
Mailing Address - Fax:231-832-1319
Practice Address - Street 1:418 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-9806
Practice Address - Country:US
Practice Address - Phone:989-352-6474
Practice Address - Fax:989-352-8451
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRUM HEALTH KELSEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-28
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1060000147208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty