MEDICARE: EMMANUEL JOHN BART-PLANGE IV PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601010541	MI
2	363A00000X	Physician Assistant	7968	WI

General Provider Information

NPI Number	:	1457934424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMANUEL JOHN BART-PLANGE IV PA

Provider Business Mailing Address
First Line	:	3290 W BIG BEAVER RD STE 150
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-2931
Country	:	US
Telephone Number	:	248-792-6527
Fax Number	:	248-792-9106

Provider Business Practice Location Address
First Line	:	25 MICHIGAN ST NE STE 6100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2561
Country	:	US
Telephone Number	:	616-267-7900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2021
Last Update Date	:	03/02/2026

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