NPIMap

Organization Active NPI

Pediatric Surgeons of West Michigan PC

  • Surgery Physician
  • Grand Rapids, MI
National Provider Identifier
1477516110
Registry record updated Mar 8, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
Legal business name
PEDIATRIC SURGEONS OF WEST MICHIGAN PC
Practice address
330 Barclay NE
Suite 202
Grand Rapids, MI 49503
Phone
(616) 458-1722
Fax
(616) 458-0061
NPI assigned
Apr 11, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 8, 2017

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

Authorized official

Name
Mrs. Jennifer L Jamula
Title
Practice Manager
Phone
(616) 458-1722

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208600000X Primary

Addresses

Primary practice location

330 Barclay NE
Suite 202
Grand Rapids, MI 49503

Mailing address

330 Barclay NE
Suite 202
Grand Rapids, MI 49503
Phone (616) 458-1722

Other identifiers 1

IdentifierTypeStateIssuer
020D176760OtherBLUE CROSS BLUE SHIELD

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080107000433 MI Part B Supplier - Clinic/Group Practice 8426138223 Receives reassigned benefits from 5 practitioners
Practice locations: Grand Rapids, MI

National Provider Directory

National Provider Directory

Locations

330 Barclay Ave NE
Ste 202
Grand Rapids, MI 49503
Phone (616) 458-1722

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1144713600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1488931200000",
    "number": "1477516110",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "330 BARCLAY NE",
            "address_2": "SUITE 202",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "49503",
            "telephone_number": "616-458-1722",
            "fax_number": "616-458-0061"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "330 BARCLAY NE",
            "address_2": "SUITE 202",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "49503",
            "telephone_number": "616-458-1722",
            "fax_number": "616-458-0061"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC SURGEONS OF WEST MICHIGAN PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-11",
        "last_updated": "2017-03-08",
        "status": "A",
        "authorized_official_last_name": "JAMULA",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "616-458-1722",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "020D176760",
            "state": null
        }
    ],
    "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 Mar 8, 2017; 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.