Provider Demographics
NPI:1609147339
Name:CALVIN UNIVERSITY
Entity type:Organization
Organization Name:CALVIN UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:DEANN
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-526-6678
Mailing Address - Street 1:3195 KNIGHT WAY SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-4409
Mailing Address - Country:US
Mailing Address - Phone:616-526-6187
Mailing Address - Fax:616-526-6548
Practice Address - Street 1:3195 KNIGHT WAY SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4406
Practice Address - Country:US
Practice Address - Phone:616-526-6187
Practice Address - Fax:616-469-1398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1558314765OtherNPI
MI4876913Medicaid
MI4202588Medicaid
MI4166848Medicaid
MI1558314765OtherNPI
MIH09131Medicare UPIN
MI4166857Medicaid