Healthcare Provider Details

I. General information

NPI: 1124083670
Provider Name (Legal Business Name): JOANNE MARIE GRZESZAK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 ALGER ST SE
GRAND RAPIDS MI
49507-3803
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW ATTN: MEDICAL ADMINISTRATION
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-7200
  • Fax: 616-452-9247
Mailing address:
  • Phone: 164-528-9236
  • Fax: 616-452-9247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101007147
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: