Provider Demographics
NPI:1518019223
Name:GRAND VALLEY STATE UNIVERSITY
Entity type:Organization
Organization Name:GRAND VALLEY STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DCHWB
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:AMOS
Authorized Official - Last Name:JONES
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:616-828-9504
Mailing Address - Street 1:10383 42ND AVE # A
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-8207
Mailing Address - Country:US
Mailing Address - Phone:616-331-2809
Mailing Address - Fax:
Practice Address - Street 1:10383 42ND AVE # A
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-8207
Practice Address - Country:US
Practice Address - Phone:616-331-2809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty