Healthcare Provider Details

I. General information

NPI: 1619990819
Provider Name (Legal Business Name): STUART VANDERHEIDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2366 OAK VALLEY DR
ANN ARBOR MI
48103-8944
US

IV. Provider business mailing address

PO BOX 1487
MUSKEGON MI
49443
US

V. Phone/Fax

Practice location:
  • Phone: 877-227-8823
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax: 616-285-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number4301076690
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number4301076690
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: