Healthcare Provider Details

I. General information

NPI: 1447324041
Provider Name (Legal Business Name): TRAVIS ANDREW LIEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE MC 49
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

578 CEDAR RIDGE DR NW APT 3B
GRAND RAPIDS MI
49544-6983
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-8879
  • Fax:
Mailing address:
  • Phone: 616-821-4344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301083941
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: