Healthcare Provider Details

I. General information

NPI: 1639382211
Provider Name (Legal Business Name): WEST MICHIGAN FAMILY PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 FOREST HILL AVE SE SUITE C
GRAND RAPIDS MI
49546-2380
US

IV. Provider business mailing address

877 FOREST HILLS SUITE C
GRAND RAPIDS MI
49546-2380
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-0402
  • Fax: 616-954-0404
Mailing address:
  • Phone: 616-954-0402
  • Fax: 616-954-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101010305
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101010305
License Number StateMI

VIII. Authorized Official

Name: DARYL M LAWRENCE-FRIEDL
Title or Position: D.O.
Credential: D.O.
Phone: 616-954-0402