Healthcare Provider Details

I. General information

NPI: 1235138397
Provider Name (Legal Business Name): MARTIN J BURY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KENMOOR AVE SE SUITE 100
GRAND RAPIDS MI
49546-2379
US

IV. Provider business mailing address

710 KENMOOR AVE SE SUITE 100
GRAND RAPIDS MI
49546-2379
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-9800
  • Fax: 616-954-2116
Mailing address:
  • Phone: 616-954-9800
  • Fax: 616-954-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4301046999
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301046999
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: