Healthcare Provider Details

I. General information

NPI: 1528873338
Provider Name (Legal Business Name): MADELEINE GRACE DECLERCQ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE STE A601
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

275 MICHIGAN ST NE FL 9
GRAND RAPIDS MI
49503-2531
US

V. Phone/Fax

Practice location:
  • Phone: 163-916-2436
  • Fax: 616-391-8611
Mailing address:
  • Phone: 616-391-6243
  • Fax: 616-391-8611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4351054806
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: