Provider Demographics
NPI:1548345879
Name:THE GRAND RIVER HEALTH SYSTEMS CORP.
Entity type:Organization
Organization Name:THE GRAND RIVER HEALTH SYSTEMS CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:H
Authorized Official - Last Name:MINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:660-646-2682
Mailing Address - Street 1:103 11TH ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-1676
Mailing Address - Country:US
Mailing Address - Phone:660-646-2682
Mailing Address - Fax:660-646-2688
Practice Address - Street 1:103 11TH ST
Practice Address - Street 2:SUITE 14
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-1554
Practice Address - Country:US
Practice Address - Phone:660-646-2682
Practice Address - Fax:660-646-2688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107238207Q00000X
MO106544207R00000X
MO2002012315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO268539Medicare ID - Type Unspecified