MEDICARE: IAIN GEMMELL CHARNLEY M.D.

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	207Q00000X	Family Medicine Physician	4301094684	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4301094684	OTHER	MI	MICHIGAN LICENSE

General Provider Information

NPI Number	:	1467680439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAIN GEMMELL CHARNLEY M.D.

Provider Business Mailing Address
First Line	:	2702 BROOKLYN AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-3939
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2080 44TH ST SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49508-5299
Country	:	US
Telephone Number	:	616-685-8100
Fax Number	:	616-455-5052

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

Provider Enumeration Date	:	06/29/2009
Last Update Date	:	12/09/2021

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