Healthcare Provider Details

I. General information

NPI: 1447299599
Provider Name (Legal Business Name): RONALD VANDERLAAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 KENMOOR AVE SE STE 101
GRAND RAPIDS MI
49546-8622
US

IV. Provider business mailing address

655 KENMOOR AVE SE STE 101
GRAND RAPIDS MI
49546-8622
US

V. Phone/Fax

Practice location:
  • Phone: 616-900-9911
  • Fax: 616-900-9862
Mailing address:
  • Phone: 616-900-9911
  • Fax: 616-900-9862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301046234
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: