Provider Demographics
NPI:1538521083
Name:GRAND RAPIDS SURGICAL ASSOCIATES, PLLC
Entity type:Organization
Organization Name:GRAND RAPIDS SURGICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGEON/FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERENT
Authorized Official - Middle Name:DOMINIQUE
Authorized Official - Last Name:PIHL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:616-634-0936
Mailing Address - Street 1:1009 44TH ST SW
Mailing Address - Street 2:STE 101
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-4480
Mailing Address - Country:US
Mailing Address - Phone:616-828-4622
Mailing Address - Fax:616-635-2552
Practice Address - Street 1:1009 44TH ST SW
Practice Address - Street 2:STE 101
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4480
Practice Address - Country:US
Practice Address - Phone:616-828-4622
Practice Address - Fax:616-635-2552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019176208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty