Healthcare Provider Details

I. General information

NPI: 1457289217
Provider Name (Legal Business Name): MADISON RAY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-844-8455
  • Fax:
Mailing address:
  • Phone: 616-844-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5151017873
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: