Healthcare Provider Details

I. General information

NPI: 1467136176
Provider Name (Legal Business Name): ANIKA RISDEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 09/01/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE SE SUITE 4000
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

200 JEFFERSON SE SUITE 305
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6922
  • Fax: 616-685-5192
Mailing address:
  • Phone: 616-685-6922
  • Fax: 616-685-5192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351050955
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: