Healthcare Provider Details

I. General information

NPI: 1174452734
Provider Name (Legal Business Name): ETHAN POLAND DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GENESYS PKWY
GRAND BLANC MI
48439-8065
US

IV. Provider business mailing address

3970 MEADOWOOD LN SW
GRANDVILLE MI
49418-2036
US

V. Phone/Fax

Practice location:
  • Phone: 810-606-5000
  • Fax:
Mailing address:
  • Phone: 616-340-0138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5151017925
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: