Healthcare Provider Details

I. General information

NPI: 1770144792
Provider Name (Legal Business Name): MICHAEL MCLANE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 MICHIGAN ST NE STE 3100
GRAND RAPIDS MI
49503-2563
US

IV. Provider business mailing address

145 MICHIGAN ST NE STE 3100
GRAND RAPIDS MI
49503-2563
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-9800
  • Fax: 616-954-1724
Mailing address:
  • Phone: 616-954-9800
  • Fax: 616-954-1724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301508816
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: