Healthcare Provider Details

I. General information

NPI: 1477599819
Provider Name (Legal Business Name): KIM J EASTMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LAFAYETTE AVE SE FOURTH FLOOR
GRAND RAPIDS MI
49503-4656
US

IV. Provider business mailing address

3565 MOMENTUM PL
CHICAGO IL
60689-5335
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-8515
  • Fax: 616-233-1108
Mailing address:
  • Phone: 616-456-8515
  • Fax: 616-233-1108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301042588
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: