Healthcare Provider Details

I. General information

NPI: 1740490200
Provider Name (Legal Business Name): MICHELLE LEE WHITFORD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE # MC-71
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC-845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-5310
  • Fax: 616-391-5343
Mailing address:
  • Phone: 616-391-5310
  • Fax: 616-391-5343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number72214
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2011-0109
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number13667
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301088600
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: