Healthcare Provider Details

I. General information

NPI: 1164044830
Provider Name (Legal Business Name): JUSTIN R STALEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

1415 E SHOREWOOD DR
NORTON SHORES MI
49441-5288
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-5000
  • Fax:
Mailing address:
  • Phone: 317-219-8571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02008975A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101026712
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: