NPIMap

Organization Active NPI

Pine Rest Christian Mental Health Services

  • Nurse Practitioner
  • Grand Rapids, MI
National Provider Identifier
1467463604
Registry record updated Nov 4, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
Legal business name
PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Practice address
300 68TH St SE
Grand Rapids, MI 49548-6927
Phone
(616) 455-5000
NPI assigned
Aug 11, 2006
Last updated
Nov 4, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
PINE REST CHRISTIAN MENTAL HEATLH SERVICESAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 4, 2020

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

Authorized official

Name
Diane Fennema
Title
Managed Care Administrator
Phone
(616) 281-6372

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse Practitioner 363L00000X NU Primary

Addresses

Primary practice location

300 68TH St SE
Grand Rapids, MI 49548-6927

Mailing address

300 68TH St SE
Grand Rapids, MI 49548-6927
Phone (616) 455-5000

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041103000525 MI Part B Supplier - Clinic/Group Practice 4981506508 Receives reassigned benefits from 38 practitioners
Practice locations: Holland, MI; Grandville, MI; Kalamazoo, MI; Lake Odessa, MI; Portage, MI; Spring Lake, MI; St Joseph, MI; Traverse City, MI…

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Pine Rest CHR M H S42 organizations share this tax ID, including this one
Part of
Pine Rest CHR M H S

Other organizations with this tax ID 41

Organizations that report the same tax identification number in the National Provider Directory.

View all 41

Locations

2118 3 Mile Rd NW
Walker, MI 49544
Phone (616) 222-3720

Practitioners & affiliated clinicians

Practitioners 39

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 39

NPI Registry JSON

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

{
    "created_epoch": "1155254400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1604448000000",
    "number": "1467463604",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 68TH ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495486927",
            "telephone_number": "616-455-5000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 68TH ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495486927",
            "telephone_number": "616-455-5000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PINE REST CHRISTIAN MENTAL HEALTH SERVICES",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PINE REST CHRISTIAN MENTAL HEATLH SERVICES",
        "enumeration_date": "2006-08-11",
        "last_updated": "2020-11-04",
        "certification_date": "2020-11-04",
        "status": "A",
        "authorized_official_last_name": "FENNEMA",
        "authorized_official_first_name": "DIANE",
        "authorized_official_title_or_position": "MANAGED CARE ADMINISTRATOR",
        "authorized_official_telephone_number": "616-281-6372"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "NU",
            "license": null,
            "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 Nov 4, 2020; 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.