Healthcare Provider Details

I. General information

NPI: 1700536604
Provider Name (Legal Business Name): AUSTIN MICHAEL VANWYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/30/2025
Certification Date: 03/30/2025
Deactivation Date: 04/03/2023
Reactivation Date: 04/13/2023

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-391-6243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4351051068
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: