NPIMap

Organization Active NPI

Cherry Street Services, Inc.

Doing business as The Salvation Army Booth Clinic

  • Family Medicine Physician
  • Grand Rapids, MI
National Provider Identifier
1063586816
Registry record updated Oct 19, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CHERRY STREET SERVICES, INC.
Doing business as
The Salvation Army Booth Clinic
Practice address
1215 Fulton St E
Grand Rapids, MI 49503-3849
Phone
(616) 459-9468
Fax
(616) 459-7223
NPI assigned
Nov 20, 2006
Last updated
Oct 19, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 19, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Chris Shea
Title
Ceo
Phone
(616) 776-2120

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Social Worker 104100000X NU
Dentist 122300000X NU
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

1215 Fulton St E
Grand Rapids, MI 49503-3849

Mailing address

100 Cherry St SE
Grand Rapids, MI 49503-4526
Phone (616) 965-8200

Other identifiers 1

IdentifierTypeStateIssuer
231857OtherMIFACILITY NUMBER

Other names 1

  • The Salvation Army Booth Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040804000274 MI Part B Supplier - Clinic/Group Practice 6800707647 Receives reassigned benefits from 133 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Grand Rapids, MI

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163980800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1350604800000",
    "number": "1063586816",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 CHERRY ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495034526",
            "telephone_number": "616-965-8200",
            "fax_number": "616-940-5366"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1215 FULTON ST E",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495033849",
            "telephone_number": "616-459-9468",
            "fax_number": "616-459-7223"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHERRY STREET SERVICES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-20",
        "last_updated": "2012-10-19",
        "status": "A",
        "authorized_official_last_name": "SHEA",
        "authorized_official_first_name": "CHRIS",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "616-776-2120"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FACILITY NUMBER",
            "identifier": "231857",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Salvation Army Booth Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.