Healthcare Provider Details

I. General information

NPI: 1063230472
Provider Name (Legal Business Name): MADELINE MCCUE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MADELINE MOSER

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 ALPINE AVE NW
GRAND RAPIDS MI
49544-1956
US

IV. Provider business mailing address

78 W 12TH ST
HOLLAND MI
49423-3213
US

V. Phone/Fax

Practice location:
  • Phone: 616-432-3591
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011926
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005936
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: