Healthcare Provider Details

I. General information

NPI: 1700403268
Provider Name (Legal Business Name): ANTOINE SASSINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LAFAYETTE AVE SE STE 3000
GRAND RAPIDS MI
49503-4692
US

IV. Provider business mailing address

PO BOX 776974
CHICAGO IL
60677-6974
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-6919
  • Fax:
Mailing address:
  • Phone: 616-685-1808
  • Fax: 312-957-2939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301518035
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: