Healthcare Provider Details

I. General information

NPI: 1992801138
Provider Name (Legal Business Name): GASTROENTEROLOGY INSTITUTE OF WEST MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 MICHIGAN ST NE SUITE A
GRAND RAPIDS MI
49503-2006
US

IV. Provider business mailing address

4100 EMBASSY DR SE SUITE 200
GRAND RAPIDS MI
49546-2416
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-6146
  • Fax: 616-459-9277
Mailing address:
  • Phone: 616-459-6146
  • Fax: 616-459-9277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateMI

VIII. Authorized Official

Name: SHAUKAT ALI KHAN
Title or Position: DOCTOR
Credential: MD
Phone: 616-459-6146