Healthcare Provider Details

I. General information

NPI: 1801048699
Provider Name (Legal Business Name): RETINA SPECIALISTS OF MICHIGAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2008
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 CASCADE RD SE
GRAND RAPIDS MI
49546-3725
US

IV. Provider business mailing address

5030 CASCADE RD SE
GRAND RAPIDS MI
49546-3725
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-2020
  • Fax: 616-949-0408
Mailing address:
  • Phone: 616-954-2020
  • Fax: 616-949-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301077476
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER DUHR
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 616-466-7562