NPIMap

Organization Active NPI

Internal Medicine and Pediatrics of West Michigan

  • Internal Medicine Physician
  • Grand Rapids, MI
National Provider Identifier
1104170661
Registry record updated Apr 15, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
4301071009 Issued in MI
Legal business name
INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN
Practice address
655 Kenmoor Ave SE
Suite 200
Grand Rapids, MI 49546
Phone
(616) 363-7690
Fax
(616) 942-8917
NPI assigned
Nov 6, 2012
Last updated
Apr 15, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 15, 2024

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

Authorized official

Name
Deanna Rawlings
Title
Office Manager
Phone
(616) 323-3227

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207R00000X 4301071009 MI Primary

Addresses

Primary practice location

655 Kenmoor Ave SE
Suite 200
Grand Rapids, MI 49546

Mailing address

655 Kenmoor Ave SE
Suite 200
Grand Rapids, MI 49546
Phone (616) 363-7690

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130215000130 MI Part B Supplier - Clinic/Group Practice 6305090507 Receives reassigned benefits from 10 practitioners
Practice locations: Grand Rapids, MI

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2049759Internal Medicine and Pediatrics of West Michigan655 Kenmoor Avenue SE Suite 200, Grand Rapids, MI 49546Certificate of waiverNov 13, 2026

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 24

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 24

NPI Registry JSON

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

{
    "created_epoch": "1352160000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1713139200000",
    "number": "1104170661",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "655 KENMOOR AVE SE",
            "address_2": "SUITE 200",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "49546",
            "telephone_number": "616-363-7690",
            "fax_number": "616-942-8917"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "655 KENMOOR AVE SE",
            "address_2": "SUITE 200",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "49546",
            "telephone_number": "616-363-7690",
            "fax_number": "616-942-8917"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTERNAL MEDICINE AND PEDIATRICS OF WEST MICHIGAN",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-11-06",
        "last_updated": "2024-04-15",
        "status": "A",
        "authorized_official_last_name": "RAWLINGS",
        "authorized_official_first_name": "DEANNA",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "616-323-3227"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "MI",
            "license": "4301071009",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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 Apr 15, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.