Healthcare Provider Details

I. General information

NPI: 1457462467
Provider Name (Legal Business Name): RICHARD PHILLIP OCONNOR JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 LAKE DR SE STE 201
GRAND RAPIDS MI
49546-8294
US

IV. Provider business mailing address

PO BOX 150185
GRAND RAPIDS MI
49515-0185
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-8200
  • Fax: 616-774-0304
Mailing address:
  • Phone: 616-866-2539
  • Fax: 616-866-3135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberRO044045
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: