Healthcare Provider Details

I. General information

NPI: 1326266404
Provider Name (Legal Business Name): ANDREW C MICHMERHUIZEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 BOSTON ST SE
GRAND RAPIDS MI
49506-4160
US

IV. Provider business mailing address

1708 MISTY RDG SW
BYRON CENTER MI
49315-8588
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101016844
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: