Provider Demographics
NPI:1396778890
Name:GRAND VALLEY GYNECOLOGISTS, P.C.
Entity type:Organization
Organization Name:GRAND VALLEY GYNECOLOGISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN DRIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-774-0700
Mailing Address - Street 1:1900 WEALTHY ST SE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2969
Mailing Address - Country:US
Mailing Address - Phone:616-774-0700
Mailing Address - Fax:616-774-0651
Practice Address - Street 1:1900 WEALTHY ST SE
Practice Address - Street 2:SUITE 330
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2969
Practice Address - Country:US
Practice Address - Phone:616-774-0700
Practice Address - Fax:616-774-0651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MII14324Medicare UPIN
MIG75343Medicare UPIN
MIA74963Medicare UPIN
MIB47293Medicare UPIN
MIA78774Medicare UPIN
MIA75925Medicare UPIN
MIB43974Medicare UPIN